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NPI Code Detail

MEDICARE: MEDICAL LABORATORY SERVICES MEDICAL GROUP, INC.

MEDICARE: MEDICAL LABORATORY SERVICES MEDICAL GROUP, 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
1207ZC0500XCytopathology Physician
2207ZP0102XAnatomic Pathology & Clinical Pathology Physician

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1063477461
Entity Type Code : Organization
Provider Name (Legal Business Name) : MEDICAL LABORATORY SERVICES MEDICAL GROUP, INC.
Provider Business Mailing Address
First Line : PO BOX 10076
Second Line :
City : VAN NUYS
State : CA
Zip : 91410-0076
Country : US
Telephone Number : 805-578-8300
Fax Number : 805-578-8950
Provider Business Practice Location Address
First Line : 36485 INLAND VALLEY DR
Second Line :
City : WILDOMAR
State : CA
Zip : 92595-9681
Country : US
Telephone Number : 760-731-3334
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : ERNEST N HOLBURT
Credential : MD
Telephone Number : 760-731-3334
Provider Enumeration Date : 04/19/2006
Last Update Date : 08/20/2009

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