1801869524 NPI number — PACIFIC AVENUE MEDICAL LABORATORY, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801869524 NPI number — PACIFIC AVENUE MEDICAL LABORATORY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFIC AVENUE MEDICAL 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:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801869524
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
728 PACIFIC AVE
Provider Second Line Business Mailing Address:
SUITE #401
Provider Business Mailing Address City Name:
SAN FRANCISCO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94133-4457
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-982-8828
Provider Business Mailing Address Fax Number:
415-982-8831

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
728 PACIFIC AVE
Provider Second Line Business Practice Location Address:
SUITE #401
Provider Business Practice Location Address City Name:
SAN FRANCISCO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94133-4457
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-982-8828
Provider Business Practice Location Address Fax Number:
415-982-8831
Provider Enumeration Date:
02/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OWYANG
Authorized Official First Name:
JOANN
Authorized Official Middle Name:
Authorized Official Title or Position:
LABORATORY MANAGER/OWNER
Authorized Official Telephone Number:
415-982-8828

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  CLF 4446 , 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: LAB58442F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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