Healthcare Provider Details

I. General information

NPI: 1114916855
Provider Name (Legal Business Name): C-S AND J PATHOLOGY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2170 SOUTH AVE BARTON MEMORIAL HOSPITAL-PATHOLOGY
SOUTH LAKE TAHOE CA
96150-7026
US

IV. Provider business mailing address

352 LINCOLN DR
VENTURA CA
93001-2322
US

V. Phone/Fax

Practice location:
  • Phone: 530-542-3000
  • Fax: 530-543-0124
Mailing address:
  • Phone: 805-652-1516
  • Fax: 805-652-2157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. MINDY ELLEN COOPER-SMITH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 805-652-1516