Provider Demographics
NPI:1497120653
Name:WESTERN DIAGNOSTIC SERVICES LABORATORY, LLC
Entity Type:Organization
Organization Name:WESTERN DIAGNOSTIC SERVICES LABORATORY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-548-1550
Mailing Address - Street 1:PO BOX 5057
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93403-5057
Mailing Address - Country:US
Mailing Address - Phone:805-242-1789
Mailing Address - Fax:
Practice Address - Street 1:1414 E MAIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-4806
Practice Address - Country:US
Practice Address - Phone:805-548-1550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-14
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory