Healthcare Provider Details

I. General information

NPI: 1184047748
Provider Name (Legal Business Name): ADVANCED FAMILY CARE MEDICAL LABORATORY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2014
Last Update Date: 01/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 E FLORENCE AVE
LOS ANGELES CA
90001-2432
US

IV. Provider business mailing address

1201 E FLORENCE AVE
LOS ANGELES CA
90001-2432
US

V. Phone/Fax

Practice location:
  • Phone: 323-588-0084
  • Fax: 323-617-3169
Mailing address:
  • Phone: 323-588-0084
  • Fax: 323-617-3169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberCLA 00322416
License Number StateCA

VIII. Authorized Official

Name: MS. LORNA MAE JOHNSON
Title or Position: ADMINISTRATOR
Credential: M.S.N., N.P., N.M.
Phone: 323-588-0084