MEDICARE: BAYLOR MIRACA GENETICS LABORATORIES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1568860062
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAYLOR MIRACA GENETICS LABORATORIES LLC

Provider Business Mailing Address
First Line	:	2450 HOLCOMBE BLVD STE 2210
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77021-2039
Country	:	US
Telephone Number	:	800-411-4363
Fax Number	:	800-434-9850

Provider Business Practice Location Address
First Line	:	2450 HOLCOMBE BLVD STE 2210
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77021-2039
Country	:	US
Telephone Number	:	800-411-4363
Fax Number	:	800-434-9850

Authorized Official
Title or Position	:	PAYOR RELATIONS SUPERVISOR
Name	:	DELORA T BENNETT
Credential	:
Telephone Number	:	281-849-7086

Provider Enumeration Date	:	12/15/2014
Last Update Date	:	05/08/2025

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