1679594287 NPI number — MICROCORRE DIAGNOSTIC LABORATORY

Table of content: (NPI 1679594287)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679594287 NPI number — MICROCORRE DIAGNOSTIC LABORATORY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICROCORRE DIAGNOSTIC LABORATORY
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:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679594287
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
890 N CHERRY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TULARE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93274-2208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-686-4000
Provider Business Mailing Address Fax Number:
559-686-9432

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
890 N CHERRY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TULARE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93274-2208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-686-4000
Provider Business Practice Location Address Fax Number:
559-686-9432
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WALTER
Authorized Official First Name:
GARY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
DIRECTOR OWNER
Authorized Official Telephone Number:
559-686-4000

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0105X , with the licence number:  CLF1717 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZZZ58691Z , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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