Provider Demographics
NPI:1497778815
Name:COGENT DIAGNOSTIC LABORATORIES, INC.
Entity Type:Organization
Organization Name:COGENT DIAGNOSTIC LABORATORIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:Y
Authorized Official - Last Name:LIU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-549-1880
Mailing Address - Street 1:2820 N ONTARIO ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91504-2015
Mailing Address - Country:US
Mailing Address - Phone:818-262-6913
Mailing Address - Fax:818-333-7186
Practice Address - Street 1:931 CALLE NEGOCIO
Practice Address - Street 2:SUITE R
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-6224
Practice Address - Country:US
Practice Address - Phone:949-369-9212
Practice Address - Fax:949-369-9220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05D1016771291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D1016771Medicare ID - Type Unspecified