Provider Demographics
NPI:1326041690
Name:MAHARLIKA MEDICAL LABORATORY, INC.
Entity Type:Organization
Organization Name:MAHARLIKA MEDICAL LABORATORY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHNNIE
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:559-233-6242
Mailing Address - Street 1:PO BOX 2032
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93718-2032
Mailing Address - Country:US
Mailing Address - Phone:559-233-6242
Mailing Address - Fax:559-233-6243
Practice Address - Street 1:1350 O ST STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721-1828
Practice Address - Country:US
Practice Address - Phone:559-233-6242
Practice Address - Fax:559-233-6243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF4565291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB58481FMedicaid
CAZZZ03941ZMedicare PIN