=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689281784
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CALIFORNIA DEPARTMENT OF PUBLIC HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2020
-----------------------------------------------------
Last Update Date | 09/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28454 LIVINGSTON AVE
-----------------------------------------------------
City | VALENCIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91355-4172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-412-5846
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 850 MARINA BAY PKWY BLDG P
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94804-6403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-412-5846
-----------------------------------------------------
Fax | 510-412-5848
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PUBLIC HEALTH LABORATORY DIRECTOR
-----------------------------------------------------
Name | DR. PAUL KIMSEY
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 510-412-5846
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------