Provider Demographics
NPI:1073920146
Name:BLOODLINE LAB MOBILE PHLEBOTOMY
Entity Type:Organization
Organization Name:BLOODLINE LAB MOBILE PHLEBOTOMY
Other - Org Name:BLOODLINE LAB
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:VILLAFUERTE
Authorized Official - Suffix:
Authorized Official - Credentials:CPT
Authorized Official - Phone:408-913-9233
Mailing Address - Street 1:1111 W EL CAMINO REAL # 109-385
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-1056
Mailing Address - Country:US
Mailing Address - Phone:408-913-9233
Mailing Address - Fax:408-913-9230
Practice Address - Street 1:830 STEWART DRIVE SUITE 229
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94085
Practice Address - Country:US
Practice Address - Phone:408-913-9233
Practice Address - Fax:408-913-3230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-21
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPT00013357246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Single Specialty