Provider Demographics
NPI:1912129222
Name:GENESIS LABORATORIES, INC.
Entity Type:Organization
Organization Name:GENESIS LABORATORIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-781-9923
Mailing Address - Street 1:5750 DIVISION ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3269
Mailing Address - Country:US
Mailing Address - Phone:951-781-9923
Mailing Address - Fax:951-781-9924
Practice Address - Street 1:5750 DIVISION ST
Practice Address - Street 2:SUITE 104
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3269
Practice Address - Country:US
Practice Address - Phone:951-781-9923
Practice Address - Fax:951-781-9924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF10367291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB76729FMedicaid
CAZZZ39948ZMedicare PIN