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General NPI Number Information
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NPI Number | 1265011464
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Entity Type | Organization
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Legal Business Name | PRAESIDIUM DIAGNOSTIC LLC
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Dates
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Enumeration Date | 04/05/2021
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Last Update Date | 03/03/2023
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Provider Practice Location Address
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Address Line | 320 LINCOLN BLVD, #100
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City | VENICE
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State | CA
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Zip | 90291
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Country | US
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Telephone | 310-807-1373
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Fax |
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Provider Business Mailing Address
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Address Line | 320 LINCOLN BOULEVARD, SUITE #100
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City | VENICE
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State | CA
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Zip | 90291
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Country | US
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Telephone | 310-807-1373
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Fax |
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Authorized Official
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Title or Position | CFO
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Name | TRAVIS OWEN
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Credential |
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Telephone | 310-807-1373
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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