=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710322441
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEST COAST PATHOLOGY LABORATORY OF AZ
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2013
-----------------------------------------------------
Last Update Date | 05/08/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 712 ALFRED NOBEL DR
-----------------------------------------------------
City | HERCULES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94547-1805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-794-9737
-----------------------------------------------------
Fax | 510-662-5244
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7200 W BELL RD, BLDG E-103
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-794-9737
-----------------------------------------------------
Fax | 510-662-5244
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LABORATORY DIRECTOR
-----------------------------------------------------
Name | JOHN COMPAGNO
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 800-794-9737
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 20624606A
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------