1518062082 NPI number — PATHNET ESOTERIC LABORATORY INSTITUTE

Table of content: (NPI 1518062082)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518062082 NPI number — PATHNET ESOTERIC LABORATORY INSTITUTE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATHNET ESOTERIC LABORATORY INSTITUTE
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:
PATHNET LABORATORY INSTITUTE SOUTH
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518062082
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7247 HAYVENHURST AVE
Provider Second Line Business Mailing Address:
SUITE A3
Provider Business Mailing Address City Name:
VAN NUYS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91406-2871
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-780-6300
Provider Business Mailing Address Fax Number:
818-781-2243

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7247 HAYVENHURST AVE
Provider Second Line Business Practice Location Address:
SUITE A3
Provider Business Practice Location Address City Name:
VAN NUYS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91406-2871
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-780-6300
Provider Business Practice Location Address Fax Number:
818-781-2243
Provider Enumeration Date:
09/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KAYE
Authorized Official First Name:
ALAN
Authorized Official Middle Name:
MITCHELL
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
818-780-6300

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  CLF1123 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 291U00000X , with the licence number: COS800143 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0589010 . This is a "IOWA MEDICAID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 269559 . This is a "OR MEDICAID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1670200 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 269558 . This is a "OR MEDICAID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: LAB17440F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: LB233CA , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 37000809 . This is a "KY MEDICAID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 37903853 . This is a "KY MEDICAID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 0970533 . This is a "IOWA MEDICAID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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