Provider Demographics
NPI:1558450601
Name:BIODATA MEDICAL LABORATORIES, INC
Entity Type:Organization
Organization Name:BIODATA MEDICAL LABORATORIES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACH
Authorized Official - Suffix:
Authorized Official - Credentials:CLS
Authorized Official - Phone:909-445-9727
Mailing Address - Street 1:691 COVEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91377-4778
Mailing Address - Country:US
Mailing Address - Phone:805-217-6212
Mailing Address - Fax:909-445-9608
Practice Address - Street 1:5494 ARROW HWY
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-1604
Practice Address - Country:US
Practice Address - Phone:909-445-9727
Practice Address - Fax:909-445-9608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF11434291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB38572FMedicaid
CAZZZ14399ZMedicare ID - Type Unspecified