Provider Demographics
NPI:1568806032
Name:MYGENETX LABORATORY LLC
Entity Type:Organization
Organization Name:MYGENETX LABORATORY LLC
Other - Org Name:LIFETIME SCIENCES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:COPELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-550-5880
Mailing Address - Street 1:6029 BELT LINE RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-9109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9 MEDICAL PKWY STE 108
Practice Address - Street 2:
Practice Address - City:FARMERS BRANCH
Practice Address - State:TX
Practice Address - Zip Code:75234-7868
Practice Address - Country:US
Practice Address - Phone:615-550-5880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-26
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory