1073642641 NPI number — PROMETHEUS LABORATORIES INC.

Table of content: (NPI 1073642641)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073642641 NPI number — PROMETHEUS LABORATORIES INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROMETHEUS 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:
1073642641
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9410 CARROLL PARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92121-5201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-824-0895
Provider Business Mailing Address Fax Number:
858-824-0896

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9410 CARROLL PARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92121-5201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-824-0895
Provider Business Practice Location Address Fax Number:
858-824-0896
Provider Enumeration Date:
03/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VASQUEZ
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
Authorized Official Title or Position:
SVP, COMMERCIAL AND CORP. DEVELOPME
Authorized Official Telephone Number:
858-587-4128

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X , with the licence number: 05D0917432 , 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: ZZZ59192Z . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 162505709 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: LAB17432F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 012894000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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