Provider Demographics
NPI:1306190129
Name:LIFE TECHNOLOGIES CLINICAL SVCS LAB INC.
Entity Type:Organization
Organization Name:LIFE TECHNOLOGIES CLINICAL SVCS LAB INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. MANAGER LABORATORY OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:760-717-6239
Mailing Address - Street 1:910 RIVERSIDE PARKWAY
Mailing Address - Street 2:SUITE 60
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95605-1510
Mailing Address - Country:US
Mailing Address - Phone:888-734-8588
Mailing Address - Fax:855-896-0909
Practice Address - Street 1:910 RIVERSIDE PARKWAY
Practice Address - Street 2:SUITE 60
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95605-1510
Practice Address - Country:US
Practice Address - Phone:888-734-8588
Practice Address - Fax:855-896-0909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-31
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05D1067109291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory