Provider Demographics
NPI:1326211301
Name:SAINT BENEDICT MEDICAL GROUP CLINICAL LABORATORY
Entity Type:Organization
Organization Name:SAINT BENEDICT MEDICAL GROUP CLINICAL LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:EDEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-479-5324
Mailing Address - Street 1:11117 S INGLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LENNOX
Mailing Address - State:CA
Mailing Address - Zip Code:90304-2514
Mailing Address - Country:US
Mailing Address - Phone:310-256-6586
Mailing Address - Fax:310-672-5900
Practice Address - Street 1:11117 S INGLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:LENNOX
Practice Address - State:CA
Practice Address - Zip Code:90304-2514
Practice Address - Country:US
Practice Address - Phone:310-256-6586
Practice Address - Fax:310-672-5900
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAINT BENEDICT MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291U00000X291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory