Provider Demographics
NPI:1972148591
Name:GENEMATRIX LABORATORY LLC
Entity type:Organization
Organization Name:GENEMATRIX LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING & CREDENTIAL SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JONI
Authorized Official - Middle Name:D
Authorized Official - Last Name:DONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-993-8374
Mailing Address - Street 1:2075 W PARK PLACE BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3542
Mailing Address - Country:US
Mailing Address - Phone:404-410-9114
Mailing Address - Fax:404-521-4665
Practice Address - Street 1:2075 W PARK PLACE BLVD STE C
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3542
Practice Address - Country:US
Practice Address - Phone:404-410-9114
Practice Address - Fax:404-521-4665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-07
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory