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General NPI Number Information
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NPI Number | 1336100759
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Entity Type | Organization
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Legal Business Name | LA GOOD SAMARITAN PATHOLOGY MEDICAL GROUP, INC.
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Dates
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Enumeration Date | 03/28/2006
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Last Update Date | 12/30/2014
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Provider Practice Location Address
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Address Line | 2777 PACIFIC AVE SUITE H201& I202
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City | LONG BEACH
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State | CA
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Zip | 90806-2625
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Country | US
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Telephone | 562-981-0100
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Fax | 562-981-0600
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Provider Business Mailing Address
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Address Line | 15021 VENTURA BLVD. SUITE #771
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City | SHERMAN OAKS
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State | CA
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Zip | 91403-2442
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Country | US
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Telephone | 562-981-0100
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Fax | 562-981-0600
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | MR. SHAHRAM KHIAL
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Credential | PH.D.
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Telephone | 818-216-0725
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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 |
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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 | CLF0001448
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License Number State | CA
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