Provider Demographics
NPI:1437103983
Name:COUNTY OF SAN LUIS OBISPO
Entity Type:Organization
Organization Name:COUNTY OF SAN LUIS OBISPO
Other - Org Name:PUBLIC HEALTH LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:805-781-5512
Mailing Address - Street 1:2191 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4534
Mailing Address - Country:US
Mailing Address - Phone:805-781-5507
Mailing Address - Fax:805-781-1023
Practice Address - Street 1:2191 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4534
Practice Address - Country:US
Practice Address - Phone:805-781-5507
Practice Address - Fax:805-781-1023
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF SAN LUIS OBISPO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-20
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA01260291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB01260FMedicaid
CALAB01260FMedicaid