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General NPI Number Information
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NPI Number | 1225316482
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Entity Type | Organization
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Legal Business Name | LAB GENOMICS, LLC
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Dates
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Enumeration Date | 07/21/2011
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Last Update Date | 08/08/2012
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Provider Practice Location Address
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Address Line | 11160 WARNER AVE STE 415
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City | FOUNTAIN VALLEY
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State | CA
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Zip | 92708-4056
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Country | US
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Telephone | 714-438-1009
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Fax | 714-438-2484
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Provider Business Mailing Address
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Address Line | 11160 WARNER AVE STE 415
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City | FOUNTAIN VALLEY
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State | CA
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Zip | 92708-4056
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Country | US
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Telephone | 714-438-1009
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Fax | 714-438-2484
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Authorized Official
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Title or Position | EXECUTIVE ADMINISTRATION
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Name | MRS. SUSHAM MANAKTALA
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Credential | CLS
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Telephone | 714-336-1379
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | CLF00341087
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License Number State | CA
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