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General NPI Number Information
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NPI Number | 1801226543
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Entity Type | Organization
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Legal Business Name | GENEX LABORATORY PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 11/15/2013
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Last Update Date | 05/16/2023
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Provider Practice Location Address
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Address Line | 3151 AIRWAY AVE STE M1
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City | COSTA MESA
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State | CA
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Zip | 92626-4626
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Country | US
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Telephone | 949-610-7253
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Fax | 949-610-7253
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Provider Business Mailing Address
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Address Line | 3151 AIRWAY AVE STE M1
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City | COSTA MESA
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State | CA
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Zip | 92626-4626
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Country | US
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Telephone | 949-610-7253
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Fax | 949-610-7253
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Authorized Official
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Title or Position | CEO
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Name | DR. DAMIEN JOHANN BURGESS
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Credential | DC, APRN, NP-C
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Telephone | 949-610-7253
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | CLF 00345153
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License Number State | CA
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