Provider Demographics
NPI:1063683357
Name:GORDON M RICK
Entity Type:Organization
Organization Name:GORDON M RICK
Other - Org Name:SCRIPPS ORAL PATHOLOGY SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:MARVIN
Authorized Official - Last Name:RICK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:858-784-0600
Mailing Address - Street 1:5190 GOVERNOR DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-2847
Mailing Address - Country:US
Mailing Address - Phone:858-784-0600
Mailing Address - Fax:858-784-0604
Practice Address - Street 1:5190 GOVERNOR DR
Practice Address - Street 2:SUITE 106
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-2847
Practice Address - Country:US
Practice Address - Phone:858-784-0600
Practice Address - Fax:858-784-0604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-14
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF11078291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB43007FMedicaid
CALAB43007FMedicaid