1457405540 NPI number — MN CLINICAL LABORATORY INC

Table of content: DR. AMADO DAVID MANDANI MD (NPI 1093894552)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457405540 NPI number — MN CLINICAL LABORATORY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MN CLINICAL 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:
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:
1457405540
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4712 ADMIRALTY WAY
Provider Second Line Business Mailing Address:
# 1010
Provider Business Mailing Address City Name:
MARINA DEL REY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90292-6905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-429-8711
Provider Business Mailing Address Fax Number:
310-577-7560

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1327 S MYRTLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROVIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91016-4150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-303-8674
Provider Business Practice Location Address Fax Number:
310-577-7560
Provider Enumeration Date:
01/23/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LEE
Authorized Official First Name:
JOON
Authorized Official Middle Name:
SUECK
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
310-429-8711

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  CLF1817 , 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: 95438506 . This is a "CHOC HEALTH ALLIANCE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: LAB72547G . This is a "CAL OPTIMA DIRECT" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: LAB72547G , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".