Provider Demographics
NPI:1023369824
Name:AMERICAN MEDICAL DIAGNOSTIC LAB INC.
Entity Type:Organization
Organization Name:AMERICAN MEDICAL DIAGNOSTIC LAB INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAHIM
Authorized Official - Middle Name:
Authorized Official - Last Name:KARJOO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-636-0261
Mailing Address - Street 1:12665 GARDEN GROVE BLVD #111
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843
Mailing Address - Country:US
Mailing Address - Phone:714-636-0261
Mailing Address - Fax:714-636-0263
Practice Address - Street 1:12665 GARDEN GROVE BLVD #111
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843
Practice Address - Country:US
Practice Address - Phone:714-636-0261
Practice Address - Fax:714-636-0263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF10400291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB73763FMedicaid