Provider Demographics
NPI:1417161993
Name:FRED SMITH-HISTO-CYTO SLIDE PREP LAB
Entity Type:Organization
Organization Name:FRED SMITH-HISTO-CYTO SLIDE PREP LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FREDDIE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MEDICAL TECH
Authorized Official - Phone:818-901-0366
Mailing Address - Street 1:16135 LEADWELL ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-3417
Mailing Address - Country:US
Mailing Address - Phone:818-901-0366
Mailing Address - Fax:
Practice Address - Street 1:16135 LEADWELL ST UNIT B
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-3417
Practice Address - Country:US
Practice Address - Phone:818-901-0366
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA246RH0600X291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
X05D000004Medicare PIN