Healthcare Provider Details

I. General information

NPI: 1154350932
Provider Name (Legal Business Name): CLIN-PATH DIAGNOSTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2109 S. 48TH STREET SUITE 102
TEMPE AZ
85282
US

IV. Provider business mailing address

PO BOX 42210
PHOENIX AZ
85080
US

V. Phone/Fax

Practice location:
  • Phone: 602-424-2889
  • Fax: 602-424-2569
Mailing address:
  • Phone: 623-889-7403
  • Fax: 623-889-7407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT DE LA TORRE
Title or Position: C.O.O.
Credential:
Phone: 602-685-5211