=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912452608
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENSYS LABS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2016
-----------------------------------------------------
Last Update Date | 08/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12150 SHILOH RD
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75228-1518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-609-7522
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 218 TANNER CREEK CIR
-----------------------------------------------------
City | SUNNYVALE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75182-9109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-567-0693
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | RONNIE HENDERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-567-0693
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------