MEDICARE: GENETIC DISEASE SCREENING PROGRAM, STATE OF CA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory	05D0862216	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	05D0862216	OTHER		CLIA

General Provider Information

NPI Number	:	1588712020
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENETIC DISEASE SCREENING PROGRAM, STATE OF CA

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

Provider Business Practice Location Address
First Line	:	850 MARINA BAY PKWY # G-272
Second Line	:
City	:	RICHMOND
State	:	CA
Zip	:	94804-6403
Country	:	US
Telephone Number	:	510-412-1502
Fax Number	:	510-412-1558

Authorized Official
Title or Position	:	CHIEF LABORATORY SERVICES BRANCH
Name	:	DR. RAJESH SHARMA
Credential	:	PHD, FACMG
Telephone Number	:	510-231-1704

Provider Enumeration Date	:	01/08/2007
Last Update Date	:	02/02/2024

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