Provider Demographics
NPI:1568158905
Name:HERITAGE LABS INC
Entity Type:Organization
Organization Name:HERITAGE LABS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AVETIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ITCHMELYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-892-5555
Mailing Address - Street 1:4741 LAUREL CANYON BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-3934
Mailing Address - Country:US
Mailing Address - Phone:818-824-3154
Mailing Address - Fax:
Practice Address - Street 1:4741 LAUREL CANYON BLVD STE 204
Practice Address - Street 2:
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-3934
Practice Address - Country:US
Practice Address - Phone:818-824-3154
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical PathologyGroup - Single Specialty