Provider Demographics
NPI:1801226543
Name:GENEX LABORATORY PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:GENEX LABORATORY PROFESSIONAL CORPORATION
Other - Org Name:GENEX LABORATORY PROFESSIONAL CORPORATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAMIEN
Authorized Official - Middle Name:JOHANN
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:DC, APRN, NP-C
Authorized Official - Phone:949-610-7253
Mailing Address - Street 1:3151 AIRWAY AVE STE M1
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-4626
Mailing Address - Country:US
Mailing Address - Phone:949-610-7253
Mailing Address - Fax:949-610-7253
Practice Address - Street 1:3151 AIRWAY AVE STE M1
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4626
Practice Address - Country:US
Practice Address - Phone:949-610-7253
Practice Address - Fax:949-610-7253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-15
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF 00345153291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory