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General NPI Number Information
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NPI Number | 1558450601
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Entity Type | Organization
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Legal Business Name | BIODATA MEDICAL LABORATORIES, INC
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Dates
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Enumeration Date | 10/12/2006
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Last Update Date | 04/19/2012
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Provider Practice Location Address
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Address Line | 5494 ARROW HWY
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City | MONTCLAIR
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State | CA
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Zip | 91763-1604
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Country | US
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Telephone | 909-445-9727
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Fax | 909-445-9608
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Provider Business Mailing Address
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Address Line | 691 COVEWOOD ST
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City | OAK PARK
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State | CA
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Zip | 91377-4778
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Country | US
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Telephone | 805-217-6212
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Fax | 909-445-9608
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Authorized Official
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Title or Position | CEO
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Name | MR. HENRY WALLACH
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Credential | CLS
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Telephone | 909-445-9727
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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 | CLF11434
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License Number State | CA
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