1336128164 NPI number — CLEVELAND SKIN PATHOLOGY LABORATORY, INC

Table of content: (NPI 1336128164)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336128164 NPI number — CLEVELAND SKIN PATHOLOGY LABORATORY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLEVELAND SKIN PATHOLOGY LABORATORY, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1336128164
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11025 RCA CENTER DRIVE
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
PALM BEACH GARDENS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-514-5822
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3737 PARK EAST DRIVE
Provider Second Line Business Practice Location Address:
SUITE #202
Provider Business Practice Location Address City Name:
BEACHWOOD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-464-7770
Provider Business Practice Location Address Fax Number:
216-464-7531
Provider Enumeration Date:
01/11/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
VALLADARES
Authorized Official First Name:
DINA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF CREDENTIALING & PE
Authorized Official Telephone Number:
561-514-5822

Provider Taxonomy Codes

  • Taxonomy code: 207ND0900X , with the licence number:  CLIA 36D0656050 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 36D0656050 . This is a "CLIA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0252560 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".