Provider Demographics
NPI:1902171424
Name:MYGENETX LABORATORY LLC
Entity type:Organization
Organization Name:MYGENETX LABORATORY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIZELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-550-5880
Mailing Address - Street 1:4037 RURAL PLAINS CIR STE 150
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37064-1868
Mailing Address - Country:US
Mailing Address - Phone:615-550-5880
Mailing Address - Fax:615-550-5889
Practice Address - Street 1:4037 RURAL PLAINS CIR STE 150
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37064-1868
Practice Address - Country:US
Practice Address - Phone:615-550-5880
Practice Address - Fax:615-550-5889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-16
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
44D2031868OtherCLIA ID NUMBER
TX45D2059216OtherCLIA