Provider Demographics
NPI:1487686556
Name:HOOSHANG DALAVARIAN, INC
Entity Type:Organization
Organization Name:HOOSHANG DALAVARIAN, INC
Other - Org Name:SOUTHERN CALIFORNIA REFERENCE LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HOOSHANG
Authorized Official - Middle Name:
Authorized Official - Last Name:DALAVARIAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:714-285-2950
Mailing Address - Street 1:100 TUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780
Mailing Address - Country:US
Mailing Address - Phone:714-285-2950
Mailing Address - Fax:714-285-2960
Practice Address - Street 1:100 TUSTIN AVE
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780
Practice Address - Country:US
Practice Address - Phone:714-285-2950
Practice Address - Fax:714-285-2960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF 11532291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB55508FMedicaid