1679015788 NPI number — AVICENNA LABORATORY DIAGNOSTICS, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679015788 NPI number — AVICENNA LABORATORY DIAGNOSTICS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVICENNA LABORATORY DIAGNOSTICS, 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:
1679015788
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20011 VENTURA BLVD STE 1002A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODLAND HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91364-2633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-914-5597
Provider Business Mailing Address Fax Number:
818-914-5596

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20011 VENTURA BLVD STE 1002A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODLAND HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91364-2633
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-914-5597
Provider Business Practice Location Address Fax Number:
818-914-5596
Provider Enumeration Date:
11/07/2016

Additional Information

Authorized Official

Authorized Official Last Name:
RUBIO
Authorized Official First Name:
PUNZALAN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
626-201-9893

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  CLF 00349262 , 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)





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