Provider Demographics
NPI:1063036689
Name:PRIVA PATH LABS, INC
Entity Type:Organization
Organization Name:PRIVA PATH LABS, INC
Other - Org Name:LGC LABS INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF BUSINESS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:KWAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-479-8489
Mailing Address - Street 1:222 E HUNTINGTON DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-8012
Mailing Address - Country:US
Mailing Address - Phone:626-479-8489
Mailing Address - Fax:888-677-7748
Practice Address - Street 1:222 E HUNTINGTON DR STE 100
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-8012
Practice Address - Country:US
Practice Address - Phone:626-479-8489
Practice Address - Fax:888-677-7748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-29
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCOVID-0013OtherNEW YORK STATE DEPARTMENT OF HEALTH
CACDF-90000517OtherCLINICAL AND PUBLIC HEALTH LABORATORY LICENSE