Provider Demographics
NPI:1225212384
Name:INDEPENDENT PHLEBOTOMY PROVIDER GROUP L.L.C.
Entity Type:Organization
Organization Name:INDEPENDENT PHLEBOTOMY PROVIDER GROUP L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHEELAH
Authorized Official - Middle Name:
Authorized Official - Last Name:ZASKE
Authorized Official - Suffix:
Authorized Official - Credentials:CPT
Authorized Official - Phone:909-482-4620
Mailing Address - Street 1:1420 N CLAREMONT BLVD
Mailing Address - Street 2:SUITE #212B
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-3528
Mailing Address - Country:US
Mailing Address - Phone:909-482-4620
Mailing Address - Fax:909-482-4623
Practice Address - Street 1:1420 N CLAREMONT BLVD
Practice Address - Street 2:SUITE #212B
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-3528
Practice Address - Country:US
Practice Address - Phone:909-482-4620
Practice Address - Fax:909-482-4623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPT19077171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty