Provider Demographics
NPI:1033141445
Name:MEDICAL LABORATORY SERVICES MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:MEDICAL LABORATORY SERVICES MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLBURT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-731-3335
Mailing Address - Street 1:PO BOX 10076
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91410-0076
Mailing Address - Country:US
Mailing Address - Phone:805-578-8300
Mailing Address - Fax:805-578-8950
Practice Address - Street 1:1667 S MISSION RD
Practice Address - Street 2:STE E & F
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-4113
Practice Address - Country:US
Practice Address - Phone:760-731-3335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory