1063849933 NPI number — INTEGRATED PATHOLOGY 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 1063849933 NPI number — INTEGRATED PATHOLOGY MEDICAL LABORATORY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTEGRATED PATHOLOGY 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:
6
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:
1063849933
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10842 NOEL ST
Provider Second Line Business Mailing Address:
SUITE# 110
Provider Business Mailing Address City Name:
LOS ALAMITOS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90720-2555
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10842 NOEL ST
Provider Second Line Business Practice Location Address:
SUITE# 110
Provider Business Practice Location Address City Name:
LOS ALAMITOS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90720-2555
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-743-5253
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/08/2013

Additional Information

Authorized Official

Authorized Official Last Name:
HISERODT
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
CHATFIELD
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
714-743-5253

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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