Provider Demographics
NPI:1598899981
Name:MICROTECHNICAL LABORATORY
Entity Type:Organization
Organization Name:MICROTECHNICAL LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:DUNHAM
Authorized Official - Suffix:
Authorized Official - Credentials:HT (ASCP)
Authorized Official - Phone:909-478-1025
Mailing Address - Street 1:11175 MOUNTAIN VIEW AVE
Mailing Address - Street 2:SUITE K
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3865
Mailing Address - Country:US
Mailing Address - Phone:909-478-1025
Mailing Address - Fax:909-478-1476
Practice Address - Street 1:11175 MOUNTAIN VIEW AVE
Practice Address - Street 2:SUITE K
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3865
Practice Address - Country:US
Practice Address - Phone:909-478-1025
Practice Address - Fax:909-478-1476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMMM00317M291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA690006239Medicare ID - Type UnspecifiedRAILROAD MEDICARE
CAMMM00317MMedicare ID - Type UnspecifiedSTANDARD MEDICARE