Healthcare Provider Details

I. General information

NPI: 1912129222
Provider Name (Legal Business Name): GENESIS LABORATORIES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 05/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5750 DIVISION ST SUITE 104
RIVERSIDE CA
92506-3269
US

IV. Provider business mailing address

5750 DIVISION ST SUITE 104
RIVERSIDE CA
92506-3269
US

V. Phone/Fax

Practice location:
  • Phone: 951-781-9923
  • Fax: 951-781-9924
Mailing address:
  • Phone: 951-781-9923
  • Fax: 951-781-9924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberCLF10367
License Number StateCA

VIII. Authorized Official

Name: DR. ROBIN DAWN CLARK
Title or Position: PRESIDENT-OWNER
Credential: M.D.
Phone: 951-781-9923