=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962095083
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LACTATION LAB INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2021
-----------------------------------------------------
Last Update Date | 02/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 570 WESTWOOD PLZ BLDG 6350
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90095-8352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-508-5265
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2315 27TH ST
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90405-1921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-998-5868
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD/ CEO/ LAB DIRECTOR
-----------------------------------------------------
Name | DR. STEPHANIE CANALE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-508-5265
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------