Provider Demographics
NPI:1659759520
Name:SYNERGENE LABORATORY LLC
Entity Type:Organization
Organization Name:SYNERGENE LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:T
Authorized Official - Last Name:WERNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-549-8355
Mailing Address - Street 1:2437 BAY AREA BLVD # 504
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058-1519
Mailing Address - Country:US
Mailing Address - Phone:936-337-7200
Mailing Address - Fax:832-532-6119
Practice Address - Street 1:5151 MITCHELLDALE ST STE B10
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77092-7200
Practice Address - Country:US
Practice Address - Phone:832-932-5968
Practice Address - Fax:832-919-6492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-12
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45D2129976OtherMEDICARE CLIA ID