1083189088 NPI number — LIFELINE MEDICAL LABORATORY INCORPORATED

Table of content: (NPI 1083189088)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083189088 NPI number — LIFELINE MEDICAL LABORATORY INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFELINE MEDICAL LABORATORY INCORPORATED
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:
1083189088
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10509 BURBANK BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH HOLLYWOOD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91601-2219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-579-4220
Provider Business Mailing Address Fax Number:
818-301-1916

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10509 BURBANK BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH HOLLYWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91601-2219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-579-4220
Provider Business Practice Location Address Fax Number:
818-301-1916
Provider Enumeration Date:
10/05/2018

Additional Information

Authorized Official

Authorized Official Last Name:
ROBLES
Authorized Official First Name:
JUAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
818-579-4220

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)

  • Identifier: CLF00333135 . This is a "CLINICAL LABORATORY LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: O5D1039663 . This is a "CLIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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