Provider Demographics
NPI:1104432970
Name:GENETICS COLLECTION LLC
Entity type:Organization
Organization Name:GENETICS COLLECTION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANTISKA
Authorized Official - Middle Name:TUJUNNA
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:318-505-2079
Mailing Address - Street 1:214 W 70TH ST STE 205
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-3756
Mailing Address - Country:US
Mailing Address - Phone:318-505-2079
Mailing Address - Fax:
Practice Address - Street 1:214 W 70TH ST STE 205
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-3756
Practice Address - Country:US
Practice Address - Phone:318-505-2079
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center