Provider Demographics
NPI:1164859757
Name:STATDIAGNOSTICS LLC
Entity Type:Organization
Organization Name:STATDIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:LOYAL
Authorized Official - Last Name:SUMMERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, CLS
Authorized Official - Phone:831-234-6684
Mailing Address - Street 1:730 N NORMA ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-3521
Mailing Address - Country:US
Mailing Address - Phone:760-375-1200
Mailing Address - Fax:760-375-1220
Practice Address - Street 1:730 N NORMA ST
Practice Address - Street 2:SUITE B
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-3521
Practice Address - Country:US
Practice Address - Phone:760-375-1200
Practice Address - Fax:760-375-1220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-27
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory