Provider Demographics
NPI:1518062082
Name:PATHNET ESOTERIC LABORATORY INSTITUTE
Entity Type:Organization
Organization Name:PATHNET ESOTERIC LABORATORY INSTITUTE
Other - Org Name:PATHNET LABORATORY INSTITUTE SOUTH
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:KAYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-780-6300
Mailing Address - Street 1:7247 HAYVENHURST AVE
Mailing Address - Street 2:SUITE A3
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-2871
Mailing Address - Country:US
Mailing Address - Phone:818-780-6300
Mailing Address - Fax:818-781-2243
Practice Address - Street 1:7247 HAYVENHURST AVE
Practice Address - Street 2:SUITE A3
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-2871
Practice Address - Country:US
Practice Address - Phone:818-780-6300
Practice Address - Fax:818-781-2243
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PATHNET ESOTERIC LABORATORY INSTITUTE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-13
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF1123291U00000X
TXCOS800143291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0589010OtherIOWA MEDICAID
TX269559OtherOR MEDICAID
TX1670200Medicaid
CA269558OtherOR MEDICAID
CALAB17440FMedicaid
ALLB233CAMedicaid
TX37000809OtherKY MEDICAID
CA37903853OtherKY MEDICAID
CA0970533OtherIOWA MEDICAID
CALAB17440FMedicaid
CA0970533OtherIOWA MEDICAID
CA37903853OtherKY MEDICAID