MEDICARE: THE LABSTER

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	261QV0200X	VA Clinic/Center

General Provider Information

NPI Number	:	1124973516
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE LABSTER

Provider Business Mailing Address
First Line	:	1015 N KENILWORTH AVE UNIT B
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91202-2822
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1015 N KENILWORTH AVE UNIT B
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91202-2822
Country	:	US
Telephone Number	:	818-482-6378
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	GREGOIR BANNA
Credential	:
Telephone Number	:	818-482-6378

Provider Enumeration Date	:	03/02/2026
Last Update Date	:	03/02/2026

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Directions to “THE LABSTER ” Practice Location

Language	Start Address	Practice Location

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