Provider Demographics
NPI:1508248527
Name:INTERNIST LABORATORY
Entity Type:Organization
Organization Name:INTERNIST LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:562-906-5227
Mailing Address - Street 1:10200 PIONEER BLVD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:SANTA FE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:90670-6000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21018 OSBORNE ST
Practice Address - Street 2:SUITE 3
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91304-1757
Practice Address - Country:US
Practice Address - Phone:562-906-5227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTERNIST LABORATORY - CANOGA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-25
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF4149291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D0696979OtherCLIA