1003369968 NPI number — PRIVILEGE DX MEDICAL LABORATORIES, INC.

Table of content: (NPI 1003369968)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003369968 NPI number — PRIVILEGE DX MEDICAL LABORATORIES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIVILEGE DX MEDICAL LABORATORIES, 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:
1003369968
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10133 RIVERSIDE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLUCA LAKE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91602-2533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
747-203-1614
Provider Business Mailing Address Fax Number:
747-205-2042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10133 RIVERSIDE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOLUCA LAKE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91602-2533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
747-203-1614
Provider Business Practice Location Address Fax Number:
747-205-2042
Provider Enumeration Date:
07/27/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BAGDASSARIAN
Authorized Official First Name:
ONICK
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
747-203-1614

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  3889342 , 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)





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