Provider Demographics
NPI:1073767620
Name:MARTHA S CRISOSTOMO
Entity Type:Organization
Organization Name:MARTHA S CRISOSTOMO
Other - Org Name:ULTIMATE RESULTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:S
Authorized Official - Last Name:CRISOSTOMO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-684-2022
Mailing Address - Street 1:1000 W 4TH ST
Mailing Address - Street 2:SUITE 375
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-1811
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 W 4TH ST
Practice Address - Street 2:SUITE 375
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-1811
Practice Address - Country:US
Practice Address - Phone:909-684-2022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-10
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05D1090838291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABR393AMedicare PIN