Healthcare Provider Details

I. General information

NPI: 1679109995
Provider Name (Legal Business Name): COMMUNITY HEALTH CLINICAL LABORATORY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2020
Last Update Date: 03/19/2020
Certification Date: 03/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 TEJAS PLACE BLDG. B SUITE A
NIPOMO CA
93444
US

IV. Provider business mailing address

150 TEJAS PLACE BLDG. B SUITE A
NIPOMO CA
93444
US

V. Phone/Fax

Practice location:
  • Phone: 805-338-0460
  • Fax:
Mailing address:
  • Phone: 805-338-0460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: ALEXANDRE FEOKTISTOV
Title or Position: PRESIDENT
Credential:
Phone: 805-338-0460