Healthcare Provider Details

I. General information

NPI: 1407099732
Provider Name (Legal Business Name): LAKEWOOD PATHOLOGY ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2009
Last Update Date: 10/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5470 BLUE RIDGE DR
YORBA LINDA CA
92887
US

IV. Provider business mailing address

6655 N MACARTHUR BLVD ATTN: PROVIDER ENROLLMENT
IRVING TX
75039-2443
US

V. Phone/Fax

Practice location:
  • Phone: 800-440-7284
  • Fax:
Mailing address:
  • Phone: 214-596-7031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DANA ARLENE SIMONDS
Title or Position: SVP, COMPLIANCE, ETHICS & QUALITY
Credential:
Phone: 214-277-8700