1588712020 NPI number — GENETIC DISEASE SCREENING PROGRAM, STATE OF CA

Table of content: (NPI 1588712020)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588712020 NPI number — GENETIC DISEASE SCREENING PROGRAM, STATE OF CA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENETIC DISEASE SCREENING PROGRAM, STATE OF CA
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:
1588712020
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
850 MARINA BAY PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94804-6403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-718-7915
Provider Business Mailing Address Fax Number:
510-412-1558

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
850 MARINA BAY PKWY # G-272
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94804-6403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-412-1502
Provider Business Practice Location Address Fax Number:
510-412-1558
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHARMA
Authorized Official First Name:
RAJESH
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF LABORATORY SERVICES BRANCH
Authorized Official Telephone Number:
510-231-1704

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  05D0862216 , 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: 05D0862216 . This is a "CLIA" identifier . This identifiers is of the category "OTHER".




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