=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306593595
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CITADEL DIAGNOSTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2022
-----------------------------------------------------
Last Update Date | 10/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1717 OLD TUSTIN AVE
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92705-7879
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-728-3270
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1267 WILLIS ST STE 200
-----------------------------------------------------
City | REDDING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96001-0400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-728-3270
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ALFREDO VALDEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-728-3270
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------