MEDICARE: IMPERIAL 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	CLF 10598	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	CLF10598	OTHER	CA	LABORATORY ID NUMBER

General Provider Information

NPI Number	:	1386788594
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPERIAL CLINICAL LABORATORY INC

Provider Business Mailing Address
First Line	:	7291 HEIL AVE
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-4467
Country	:	US
Telephone Number	:	714-375-0800
Fax Number	:	714-375-0814

Provider Business Practice Location Address
First Line	:	7291 HEIL AVE
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-0000
Country	:	US
Telephone Number	:	714-375-0800
Fax Number	:	714-375-0814

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. LUKE WATSON
Credential	:	M.D.
Telephone Number	:	714-375-0800

Provider Enumeration Date	:	02/19/2007
Last Update Date	:	03/07/2008

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