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General NPI Number Information
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NPI Number | 1669135661
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Entity Type | Organization
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Legal Business Name | SOURCE BIOSCIENCE INC
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Dates
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Enumeration Date | 10/16/2021
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Last Update Date | 10/16/2021
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Provider Practice Location Address
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Address Line | 6696 MESA RIDGE RD STE B
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City | SAN DIEGO
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State | CA
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Zip | 92121-2950
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Country | US
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Telephone | 858-344-7993
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Fax |
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Provider Business Mailing Address
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Address Line | 6696 MESA RIDGE RD STE B
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City | SAN DIEGO
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State | CA
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Zip | 92121-2950
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Country | US
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Telephone | 858-344-7993
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Fax |
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Authorized Official
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Title or Position | LAB CONSULTANT
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Name | MICHAEL YU
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Credential | MS, MBA, MLS (ASCP)
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Telephone | 626-236-2706
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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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