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General NPI Number Information
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NPI Number | 1578452215
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Entity Type | Organization
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Legal Business Name | MEDICAL DIAGNOSTIC AND PROGNOSTIC LABORATORY
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Dates
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Enumeration Date | 06/30/2025
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Last Update Date | 06/30/2025
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Provider Practice Location Address
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Address Line | 4117 SOUTH ST
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City | LAKEWOOD
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State | CA
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Zip | 90712-1043
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Country | US
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Telephone | 562-723-6732
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Fax |
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Provider Business Mailing Address
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Address Line | 14 STALLION RD
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City | RANCHO PALOS VERDES
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State | CA
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Zip | 90275-5257
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Country | US
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Telephone | 310-567-9213
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. KIAT YEONG CHAN
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Credential | MD
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Telephone | 310-567-9213
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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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