Provider Demographics
NPI:1518142090
Name:ANTIOCH MEDICAL PARK MEDICAL LAB
Entity Type:Organization
Organization Name:ANTIOCH MEDICAL PARK MEDICAL LAB
Other - Org Name:ANTIOCH MEDICAL PARK LAB
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:J
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:ZIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-754-9223
Mailing Address - Street 1:3737 LONE TREE WAY
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-6065
Mailing Address - Country:US
Mailing Address - Phone:925-754-1254
Mailing Address - Fax:925-754-1764
Practice Address - Street 1:3737 LONE TREE WAY
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-6065
Practice Address - Country:US
Practice Address - Phone:925-754-1254
Practice Address - Fax:925-754-1764
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANTIOCH MEDICAL PARK MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-03
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALAB97463F291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB97463FMedicaid
CAZZZ76320ZMedicare PIN