Healthcare Provider Details

I. General information

NPI: 1407813777
Provider Name (Legal Business Name): HISTO-PATH TECHNICAL SPECIALTIES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4847 KIERNAN CT STE 1
SALIDA CA
95368-9524
US

IV. Provider business mailing address

PO BOX 4978
MODESTO CA
95352-4978
US

V. Phone/Fax

Practice location:
  • Phone: 209-575-4575
  • Fax: 209-575-4598
Mailing address:
  • Phone: 209-575-4575
  • Fax: 209-575-4598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246QH0600X
TaxonomyHistology Specialist/Technologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: LISA MICHELLE DANIEL
Title or Position: VP, BILLING MGR
Credential:
Phone: 209-522-8240