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General NPI Number Information
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NPI Number | 1881833036
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Entity Type | Organization
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Legal Business Name | PROFESSIONAL CLINICAL LABORATORY
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Dates
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Enumeration Date | 02/11/2009
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Last Update Date | 06/25/2013
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Provider Practice Location Address
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Address Line | 432 S SAN VICENTE BLVD # 200A SUITE 200
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City | LOS ANGELES
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State | CA
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Zip | 90048-4183
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Country | US
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Telephone | 310-360-0066
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Fax | 310-360-0302
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Provider Business Mailing Address
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Address Line | 432 S SAN VICENTE BLVD SUITE 200A
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City | LOS ANGELES
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State | CA
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Zip | 90048-4183
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Country | US
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Telephone | 310-360-0022
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Fax | 310-360-0302
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. JOHN SHAYEFAR
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Credential |
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Telephone | 310-360-0022
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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 | 05D2048878
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License Number State | CA
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