Healthcare Provider Details

I. General information

NPI: 1801869524
Provider Name (Legal Business Name): PACIFIC AVENUE MEDICAL LABORATORY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 PACIFIC AVE SUITE #401
SAN FRANCISCO CA
94133-4457
US

IV. Provider business mailing address

728 PACIFIC AVE SUITE #401
SAN FRANCISCO CA
94133-4457
US

V. Phone/Fax

Practice location:
  • Phone: 415-982-8828
  • Fax: 415-982-8831
Mailing address:
  • Phone: 415-982-8828
  • Fax: 415-982-8831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberCLF 4446
License Number StateCA

VIII. Authorized Official

Name: MS. JOANN OWYANG
Title or Position: LABORATORY MANAGER/OWNER
Credential: CLS
Phone: 415-982-8828