Provider Demographics
NPI:1285160887
Name:GENLAB CORPORATION
Entity type:Organization
Organization Name:GENLAB CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEJANDRO
Authorized Official - Middle Name:
Authorized Official - Last Name:PABRIAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:725-777-8066
Mailing Address - Street 1:1417 SE 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-1805
Mailing Address - Country:US
Mailing Address - Phone:954-530-8332
Mailing Address - Fax:954-533-7605
Practice Address - Street 1:1417 SE 1ST AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-1805
Practice Address - Country:US
Practice Address - Phone:954-530-8332
Practice Address - Fax:954-533-7605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14D1082277291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216788Medicare PIN