MEDICARE: GENOSCREEN LAB LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1306652037
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENOSCREEN LAB LLC

Provider Business Mailing Address
First Line	:	6127 S UNIVERSITY AVE STE 1274
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60637-7505
Country	:	US
Telephone Number	:	773-782-6355
Fax Number	:	773-782-6322

Provider Business Practice Location Address
First Line	:	6127 S UNIVERSITY AVE STE 1274
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60637-7505
Country	:	US
Telephone Number	:	773-782-6355
Fax Number	:	773-782-6322

Authorized Official
Title or Position	:	OWNER
Name	:	MS. TONISA JAMES
Credential	:
Telephone Number	:	202-821-6633

Provider Enumeration Date	:	12/07/2024
Last Update Date	:	12/07/2024

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