Provider Demographics
NPI:1700403425
Name:GENESIS PROJECT MEDICAL LABORATORY
Entity Type:Organization
Organization Name:GENESIS PROJECT MEDICAL LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TRASHA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:704-596-0505
Mailing Address - Street 1:5104 REAGAN DR STE 5
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28206-1392
Mailing Address - Country:US
Mailing Address - Phone:704-596-0505
Mailing Address - Fax:
Practice Address - Street 1:1000 ANDERSON ST STE A
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-1216
Practice Address - Country:US
Practice Address - Phone:704-596-0505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESIS PROJECT 1, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-06-29
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory