=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780010272
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENQUEST DNA ANALYSIS LABORATORY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2013
-----------------------------------------------------
Last Update Date | 09/17/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 133 CONEY ISLAND DR
-----------------------------------------------------
City | SPARKS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89431-6317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-358-0652
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 133 CONEY ISLAND DR
-----------------------------------------------------
City | SPARKS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89431-6317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-358-0652
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. STEPHEN ST. JEOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 775-358-0652
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | NV20031054361
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------