MEDICARE: HUNTINGTON BEACH CLINICAL LABORATORY

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 334485	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CLF 334485	OTHER	CA	CLIA # 05D1080532

General Provider Information

NPI Number	:	1992942783
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HUNTINGTON BEACH CLINICAL LABORATORY

Provider Business Mailing Address
First Line	:	8071 SLATER AVE
Second Line	:	SUITE 100
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-6960
Country	:	US
Telephone Number	:	714-841-7789
Fax Number	:	714-841-9966

Provider Business Practice Location Address
First Line	:	8071 SLATER AVE
Second Line	:	SUITE 100
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-6960
Country	:	US
Telephone Number	:	714-841-7789
Fax Number	:	714-841-9966

Authorized Official
Title or Position	:	OWNER
Name	:	MISS LOTA N RELATO
Credential	:	NURSE
Telephone Number	:	714-841-7789

Provider Enumeration Date	:	01/15/2009
Last Update Date	:	01/15/2009

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