MEDICARE: GENESIS REFERENCE LABORATORIES, 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982091617
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENESIS REFERENCE LABORATORIES, LLC

Provider Business Mailing Address
First Line	:	7924 FOREST CITY RD STE 210
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32810-2925
Country	:	US
Telephone Number	:	407-232-7172
Fax Number	:	407-289-4082

Provider Business Practice Location Address
First Line	:	7924 FOREST CITY RD STE 210
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32810-2925
Country	:	US
Telephone Number	:	407-232-7172
Fax Number	:	407-289-4082

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	PHILIP DAVID FREITAS
Credential	:
Telephone Number	:	407-232-7172

Provider Enumeration Date	:	04/21/2015
Last Update Date	:	05/16/2019

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