MEDICARE: PRIVILEGE DX MEDICAL LABORATORIES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory	3889342	CA

General Provider Information

NPI Number	:	1003369968
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIVILEGE DX MEDICAL LABORATORIES, INC.

Provider Business Mailing Address
First Line	:	10133 RIVERSIDE DR
Second Line	:
City	:	TOLUCA LAKE
State	:	CA
Zip	:	91602-2533
Country	:	US
Telephone Number	:	747-203-1614
Fax Number	:	747-205-2042

Provider Business Practice Location Address
First Line	:	10133 RIVERSIDE DR
Second Line	:
City	:	TOLUCA LAKE
State	:	CA
Zip	:	91602-2533
Country	:	US
Telephone Number	:	747-203-1614
Fax Number	:	747-205-2042

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ONICK BAGDASSARIAN
Credential	:	OWNER
Telephone Number	:	747-203-1614

Provider Enumeration Date	:	07/27/2016
Last Update Date	:	07/24/2019

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