=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083842041
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATHSERVE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2009
-----------------------------------------------------
Last Update Date | 02/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 963 INDUSTRIAL RD SUITE F
-----------------------------------------------------
City | SAN CARLOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94070-4145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-664-9686
-----------------------------------------------------
Fax | 415-294-4554
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 963 INDUSTRIAL RD SUITE F
-----------------------------------------------------
City | SAN CARLOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94070-4145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-664-9686
-----------------------------------------------------
Fax | 415-294-4554
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. ROMAN KARP
-----------------------------------------------------
Credential | CERT. PATH ASSISTANT
-----------------------------------------------------
Telephone | 415-664-9686
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------