Provider Demographics
NPI:1336100759
Name:LA GOOD SAMARITAN PATHOLOGY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:LA GOOD SAMARITAN PATHOLOGY MEDICAL GROUP, INC.
Other - Org Name:ADVANCED CLINICAL LABORATORIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAHRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KHIAL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:818-216-0725
Mailing Address - Street 1:15021 VENTURA BLVD.
Mailing Address - Street 2:SUITE #771
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-2442
Mailing Address - Country:US
Mailing Address - Phone:562-981-0100
Mailing Address - Fax:562-981-0600
Practice Address - Street 1:2777 PACIFIC AVE
Practice Address - Street 2:SUITE H201& I202
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2625
Practice Address - Country:US
Practice Address - Phone:562-981-0100
Practice Address - Fax:562-981-0600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
291U00000X
CACLF0001448291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ55908ZOtherBLUE SHIELD
CAED741AOtherPTAN ID #
CALAB02841FMedicaid