MEDICARE: HERITAGE LABS 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	207ZC0006X	Clinical Pathology Physician

General Provider Information

NPI Number	:	1568158905
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERITAGE LABS INC

Provider Business Mailing Address
First Line	:	4741 LAUREL CANYON BLVD STE 204
Second Line	:
City	:	VALLEY VILLAGE
State	:	CA
Zip	:	91607-3934
Country	:	US
Telephone Number	:	818-824-3154
Fax Number	:

Provider Business Practice Location Address
First Line	:	4741 LAUREL CANYON BLVD STE 204
Second Line	:
City	:	VALLEY VILLAGE
State	:	CA
Zip	:	91607-3934
Country	:	US
Telephone Number	:	818-824-3154
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	AVETIS ITCHMELYAN
Credential	:
Telephone Number	:	323-892-5555

Provider Enumeration Date	:	04/17/2023
Last Update Date	:	04/17/2023

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Directions to “HERITAGE LABS INC ” Practice Location

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