Provider Demographics
NPI:1114060522
Name:PUBLIC HEALTH LAB, SAN JOAQUIN CO PUB HLTH SVS
Entity Type:Organization
Organization Name:PUBLIC HEALTH LAB, SAN JOAQUIN CO PUB HLTH SVS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR PUBLIC HEALTH SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:209-468-3413
Mailing Address - Street 1:PO BOX 2009
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95201-2009
Mailing Address - Country:US
Mailing Address - Phone:209-468-3413
Mailing Address - Fax:209-468-2072
Practice Address - Street 1:1601 E HAZELTON AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-6229
Practice Address - Country:US
Practice Address - Phone:209-468-3413
Practice Address - Fax:209-468-2072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB58566FMedicare UPIN