Provider Demographics
NPI:1366625501
Name:CONEJO HISTOLOGY LAB
Entity Type:Organization
Organization Name:CONEJO HISTOLOGY LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GE SUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:CHOI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-991-6410
Mailing Address - Street 1:31304 VIA COLINAS
Mailing Address - Street 2:SUITE #109
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91362-4591
Mailing Address - Country:US
Mailing Address - Phone:818-991-6410
Mailing Address - Fax:
Practice Address - Street 1:31304 VIA COLINAS
Practice Address - Street 2:SUITE #109
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91362-4591
Practice Address - Country:US
Practice Address - Phone:818-991-6410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAX05D000007Medicare PIN