=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720678980
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENCO LAB LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2021
-----------------------------------------------------
Last Update Date | 04/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7 SYCAMORE WAY UNIT 9
-----------------------------------------------------
City | BRANFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06405-6529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 475-338-1169
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 SYCAMORE WAY UNIT 9
-----------------------------------------------------
City | BRANFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06405-6529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 475-338-1169
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PAUL CONROY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 475-338-1169
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------