Provider Demographics
NPI:1073642641
Name:PROMETHEUS LABORATORIES INC.
Entity Type:Organization
Organization Name:PROMETHEUS LABORATORIES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP, COMMERCIAL AND CORP. DEVELOPME
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:VASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-587-4128
Mailing Address - Street 1:9410 CARROLL PARK DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-5201
Mailing Address - Country:US
Mailing Address - Phone:858-824-0895
Mailing Address - Fax:858-824-0896
Practice Address - Street 1:9410 CARROLL PARK DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-5201
Practice Address - Country:US
Practice Address - Phone:858-824-0895
Practice Address - Fax:858-824-0896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05D0917432291U00000X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ59192ZOtherBLUE SHIELD
AR162505709Medicaid
CALAB17432FMedicaid
CALAB17432FMedicaid