Provider Demographics
NPI:1649636275
Name:GENETICARE LABORATORY INC.
Entity type:Organization
Organization Name:GENETICARE LABORATORY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CAMILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-344-2920
Mailing Address - Street 1:2901 UNION RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63125-3972
Mailing Address - Country:US
Mailing Address - Phone:314-200-3109
Mailing Address - Fax:314-200-3107
Practice Address - Street 1:2901 UNION RD
Practice Address - Street 2:SUITE 250
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125-3972
Practice Address - Country:US
Practice Address - Phone:314-200-3109
Practice Address - Fax:314-200-3107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO26D2014386291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO26D2014386OtherCLIA