Provider Demographics
NPI:1093044604
Name:CCRMED INC
Entity Type:Organization
Organization Name:CCRMED INC
Other - Org Name:CENTRAL UTAH PATHOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEON
Authorized Official - Middle Name:TAN
Authorized Official - Last Name:QUE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:818-924-0525
Mailing Address - Street 1:23705 VANOWEN ST
Mailing Address - Street 2:SUITE 151
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-3030
Mailing Address - Country:US
Mailing Address - Phone:818-924-0525
Mailing Address - Fax:818-936-0198
Practice Address - Street 1:7301 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 200
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91307-1904
Practice Address - Country:US
Practice Address - Phone:818-924-0525
Practice Address - Fax:818-936-0198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-09
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT46D0992374291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory