MEDICARE: PREMIERE CLINICAL LABORATORY,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	CLF00321668	CA

General Provider Information

NPI Number	:	1235215641
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIERE CLINICAL LABORATORY,INC.

Provider Business Mailing Address
First Line	:	11900 SOUTH AVALON BLVD.
Second Line	:	SUITE#100
City	:	LOS ANGELES
State	:	CA
Zip	:	90061-2837
Country	:	US
Telephone Number	:	323-756-1317
Fax Number	:	323-756-4015

Provider Business Practice Location Address
First Line	:	11900 SOUTH AVALON BLVD.
Second Line	:	SUITE#100
City	:	LOS ANGELES
State	:	CA
Zip	:	90061-2837
Country	:	US
Telephone Number	:	323-756-1317
Fax Number	:	323-756-4015

Authorized Official
Title or Position	:	DIRECTOR/OWNER
Name	:	JACK AZAD
Credential	:	M.D.
Telephone Number	:	323-756-1317

Provider Enumeration Date	:	10/27/2006
Last Update Date	:	05/18/2011

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