Provider Demographics
NPI:1467844407
Name:BR LAB AND RADIOLOGY
Entity Type:Organization
Organization Name:BR LAB AND RADIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BAO
Authorized Official - Middle Name:THAI
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:424-488-0500
Mailing Address - Street 1:555 PIER AVE
Mailing Address - Street 2:STE #1
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-3839
Mailing Address - Country:US
Mailing Address - Phone:424-488-0500
Mailing Address - Fax:
Practice Address - Street 1:555 PIER AVE
Practice Address - Street 2:STE #1
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-3839
Practice Address - Country:US
Practice Address - Phone:424-488-0500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-27
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA95636208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty