MEDICARE: PATH LABS, LLC

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	G78120	CA
2	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1710983671
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATH LABS, LLC

Provider Business Mailing Address
First Line	:	1166 NATIONAL DR STE 80
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95834-1978
Country	:	US
Telephone Number	:	916-863-1496
Fax Number	:	877-405-9837

Provider Business Practice Location Address
First Line	:	1166 NATIONAL DR STE 80
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95834-1978
Country	:	US
Telephone Number	:	916-863-1496
Fax Number	:	877-405-9837

Authorized Official
Title or Position	:	CEO/MEDICAL DIRECTOR
Name	:	DR. PETER KOLBECK
Credential	:	MD
Telephone Number	:	916-863-1496

Provider Enumeration Date	:	06/24/2005
Last Update Date	:	02/23/2018

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