Provider Demographics
NPI:1750846945
Name:GENLABX LLC
Entity type:Organization
Organization Name:GENLABX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:HAMIDREZA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAHEDIPOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-501-4899
Mailing Address - Street 1:1939 ROLAND CLARKE PL STE 100
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-1443
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1939 ROLAND CLARKE PL STE 100
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-1443
Practice Address - Country:US
Practice Address - Phone:202-999-2564
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083T0002XAllopathic & Osteopathic PhysiciansPreventive MedicineMedical ToxicologyGroup - Single Specialty