Provider Demographics
NPI:1598191512
Name:PATHOLOGY ASSOCIATES LABORATORY OF SOUTHERN CALIFORNIA
Entity Type:Organization
Organization Name:PATHOLOGY ASSOCIATES LABORATORY OF SOUTHERN CALIFORNIA
Other - Org Name:PATHOLOGY ASSOCIATES LABORATORY OF SOUTHERN CALIFORNIA INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:XIANGDONG
Authorized Official - Middle Name:
Authorized Official - Last Name:BU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-818-0600
Mailing Address - Street 1:520 N BROOKHURST ST # 228
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801
Mailing Address - Country:US
Mailing Address - Phone:714-818-0600
Mailing Address - Fax:714-590-4888
Practice Address - Street 1:520 N BROOKHURST ST # 228
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801
Practice Address - Country:US
Practice Address - Phone:714-818-0600
Practice Address - Fax:714-590-4888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-23
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB51370FMedicaid
CA05D0951370Medicare Oscar/Certification
CALAB51370FMedicaid