Provider Demographics
NPI:1033444567
Name:SAMRA LABORATORY SERVICE, INC.
Entity Type:Organization
Organization Name:SAMRA LABORATORY SERVICE, INC.
Other - Org Name:UNIMED IMAGING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KESUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:KWAK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:213-384-1424
Mailing Address - Street 1:1730 W OLYMPIC BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-1019
Mailing Address - Country:US
Mailing Address - Phone:213-384-1424
Mailing Address - Fax:213-384-1101
Practice Address - Street 1:1730 W OLYMPIC BLVD
Practice Address - Street 2:STE 101
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-1019
Practice Address - Country:US
Practice Address - Phone:213-384-1424
Practice Address - Fax:213-384-1101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-16
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85846261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC30810OtherCALIFORNIA CHIROPRACTIC BOARD
CAWA85846IMedicare PIN