1790950145 NPI number — PATHNET LAB INSTITUTE SOUTH

Table of content: (NPI 1790950145)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790950145 NPI number — PATHNET LAB INSTITUTE SOUTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATHNET LAB INSTITUTE SOUTH
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:
1790950145
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7247 HAYVENHURST AVE
Provider Second Line Business Mailing Address:
SUITE A3
Provider Business Mailing Address City Name:
VAN NUYS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91406-2871
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-780-6300
Provider Business Mailing Address Fax Number:
818-781-2243

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2391 NE LOOP 410
Provider Second Line Business Practice Location Address:
MARYMONT BUSINESS CENTRE BUILDING 3 SUITE 309
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78217-5600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-780-6300
Provider Business Practice Location Address Fax Number:
818-781-2243
Provider Enumeration Date:
04/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KAYE
Authorized Official First Name:
ALAN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT CEO
Authorized Official Telephone Number:
818-780-6300

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  COS800143 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1670200 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 269559 . This is a "OR MEDICAID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 37000809 . This is a "KY MEDICAID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 45D0972921 . This is a "CLIA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0589010 . This is a "IOWA MEDICAID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 404539401 . This is a "MD MEDICAID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 112130800 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 404539400 . This is a "MD MEDICAID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: LB233CA , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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