=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801044508
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICAL SCIENCE LABORATORY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2008
-----------------------------------------------------
Last Update Date | 03/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 432 S SAN VICENTE BLVD STE 200
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90048-4192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-360-0066
-----------------------------------------------------
Fax | 310-360-0302
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 432 S SAN VICENTE BLVD STE 220
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90048-4183
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-360-0066
-----------------------------------------------------
Fax | 310-360-0302
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. KAMBAKSH TAVAKOLI
-----------------------------------------------------
Credential | CHS
-----------------------------------------------------
Telephone | 310-360-0066
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 05D1082642
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------