Provider Demographics
NPI:1720678980
Name:GENCO LAB LLC
Entity Type:Organization
Organization Name:GENCO LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:CONROY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:475-338-1169
Mailing Address - Street 1:7 SYCAMORE WAY UNIT 9
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-6529
Mailing Address - Country:US
Mailing Address - Phone:475-338-1169
Mailing Address - Fax:
Practice Address - Street 1:7 SYCAMORE WAY UNIT 9
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-6529
Practice Address - Country:US
Practice Address - Phone:475-338-1169
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-21
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008103556Medicaid
ME1212700001Medicaid
RI1720678980Medicaid