=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306190129
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE TECHNOLOGIES CLINICAL SVCS LAB INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2012
-----------------------------------------------------
Last Update Date | 03/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 910 RIVERSIDE PARKWAY SUITE 60
-----------------------------------------------------
City | WEST SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95605-1510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-734-8588
-----------------------------------------------------
Fax | 855-896-0909
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 910 RIVERSIDE PARKWAY SUITE 60
-----------------------------------------------------
City | WEST SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95605-1510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-734-8588
-----------------------------------------------------
Fax | 855-896-0909
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR. MANAGER LABORATORY OPERATIONS
-----------------------------------------------------
Name | MR. ALAN EUGENE WELLS SR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 760-717-6239
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 05D1067109
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------