Provider Demographics
NPI:1437105517
Name:LARCHMONT DIAGNOSTIC LABORATORIES, INC.
Entity Type:Organization
Organization Name:LARCHMONT DIAGNOSTIC LABORATORIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DMITRY
Authorized Official - Middle Name:
Authorized Official - Last Name:PERSONOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-461-9100
Mailing Address - Street 1:321 N LARCHMONT BLVD
Mailing Address - Street 2:425
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-3025
Mailing Address - Country:US
Mailing Address - Phone:323-461-9100
Mailing Address - Fax:323-461-9120
Practice Address - Street 1:321 N LARCHMONT BLVD
Practice Address - Street 2:425
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-3025
Practice Address - Country:US
Practice Address - Phone:323-461-9100
Practice Address - Fax:323-461-9120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D0964049Medicare ID - Type UnspecifiedCLIA ID NUMBER