Healthcare Provider Details

I. General information

NPI: 1639562309
Provider Name (Legal Business Name): LIQUIDX LABORATORY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2015
Last Update Date: 08/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1403 W OAK ST
STOCKTON CA
95203-2607
US

IV. Provider business mailing address

1403 W OAK ST
STOCKTON CA
95203-2607
US

V. Phone/Fax

Practice location:
  • Phone: 209-323-4126
  • Fax:
Mailing address:
  • Phone: 209-323-4126
  • 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: MR. CHARLIE PARKER
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 530-306-2488