Healthcare Provider Details

I. General information

NPI: 1104266840
Provider Name (Legal Business Name): AMERICAN TOXICOLOGY MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2013
Last Update Date: 06/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1464 MADERA RD # N-137
SIMI VALLEY CA
93065-3077
US

IV. Provider business mailing address

1464 MADERA RD # N-137
SIMI VALLEY CA
93065-3077
US

V. Phone/Fax

Practice location:
  • Phone: 805-416-1648
  • Fax:
Mailing address:
  • Phone: 805-416-1648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SHANNON PORTER
Title or Position: SUPERVISOR
Credential:
Phone: 805-416-1648