Provider Demographics
NPI:1396830204
Name:INTERNIST LABORATORY
Entity Type:Organization
Organization Name:INTERNIST LABORATORY
Other - Org Name:VANTAGEPOINT LABORATORY PARTNERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-906-5227
Mailing Address - Street 1:4980 CARROLL CANYON RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1736
Mailing Address - Country:US
Mailing Address - Phone:858-638-8120
Mailing Address - Fax:858-638-8298
Practice Address - Street 1:10200 PIONEER BLVD
Practice Address - Street 2:SUITE 500
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-6000
Practice Address - Country:US
Practice Address - Phone:562-906-5227
Practice Address - Fax:562-906-6450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF 2678291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
05D0643041OtherCLIA