Provider Demographics
NPI:1467658849
Name:UNIVERSITY OF SOUTHERN CALIFORNIA
Entity Type:Organization
Organization Name:UNIVERSITY OF SOUTHERN CALIFORNIA
Other - Org Name:USC IMMUNOHISTOCHEMISTRY LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP ADMINISTRATION
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-740-8184
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-1156
Mailing Address - Fax:
Practice Address - Street 1:2011 ZONAL AVE
Practice Address - Street 2:HRM 308 AND 310
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0110
Practice Address - Country:US
Practice Address - Phone:323-442-1156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF SOUTHERN CALIFORNIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-22
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB33784FMedicaid
CA05D1033784OtherCLIA NUMBER
CLF332197OtherSTATE LIC
CA690000015OtherMEDICARE RAILROAD
CALAB33784FMedicaid
CALAB33784FMedicaid