Provider Demographics
NPI:1619475290
Name:LUCID GENETICS, CORP.
Entity Type:Organization
Organization Name:LUCID GENETICS, CORP.
Other - Org Name:LUCID GENETICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEIGH
Authorized Official - Middle Name:JENNINGS
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:727-249-8241
Mailing Address - Street 1:970 LAKE CARILLON DR STE 300
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-1130
Mailing Address - Country:US
Mailing Address - Phone:727-249-8241
Mailing Address - Fax:
Practice Address - Street 1:970 LAKE CARILLON DR STE 300
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-1130
Practice Address - Country:US
Practice Address - Phone:727-249-8241
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-29
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QG0250XAmbulatory Health Care FacilitiesClinic/CenterGenetics