Provider Demographics
NPI:1063044097
Name:GENUS3 LLC
Entity Type:Organization
Organization Name:GENUS3 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-590-7089
Mailing Address - Street 1:25319 INTERSTATE 45 STE 102
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77380-3551
Mailing Address - Country:US
Mailing Address - Phone:832-603-1086
Mailing Address - Fax:866-252-3902
Practice Address - Street 1:25319 INTERSTATE 45 STE 102
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77380-3551
Practice Address - Country:US
Practice Address - Phone:832-603-1086
Practice Address - Fax:866-252-3902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
45D2176742OtherCLIA