1356755516 NPI number — VIBRANT AMERICA CLINICAL LABORATORY

Table of content: (NPI 1356755516)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356755516 NPI number — VIBRANT AMERICA CLINICAL LABORATORY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIBRANT AMERICA CLINICAL LABORATORY
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:
1356755516
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1021 HOWARD AVE
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
SAN CARLOS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94070-4028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-226-3381
Provider Business Mailing Address Fax Number:
650-226-3381

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1021 HOWARD AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SAN CARLOS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94070-4028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-226-3381
Provider Business Practice Location Address Fax Number:
650-226-3381
Provider Enumeration Date:
06/16/2014

Additional Information

Authorized Official

Authorized Official Last Name:
RAJASEKARAN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
650-808-5824

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  CLF 00346278 , 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: 05D2078809 . This is a "CLIA NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: CLF 00346278 . This is a "CALIFORNIA LABORATORY LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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