MEDICARE: UNILAB CORPORATION

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	05D0700053	CA

General Provider Information

NPI Number	:	1649315821
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNILAB CORPORATION

Provider Business Mailing Address
First Line	:	1201 S COLLEGEVILLE RD
Second Line	:
City	:	COLLEGEVILLE
State	:	PA
Zip	:	19426-2998
Country	:	US
Telephone Number	:	866-697-8378
Fax Number	:

Provider Business Practice Location Address
First Line	:	2291 W MARCH LANE
Second Line	:	SUITE 145 F
City	:	STOCKTON
State	:	CA
Zip	:	95207-6652
Country	:	US
Telephone Number	:	209-951-5831
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	CHARLES ALBERT BOWLES
Credential	:
Telephone Number	:	610-454-6000

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	12/11/2018

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