Provider Demographics
NPI:1619175312
Name:CCL LABORATORIES INC
Entity Type:Organization
Organization Name:CCL LABORATORIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:BERNADETTE
Authorized Official - Middle Name:J
Authorized Official - Last Name:VILLANUEVA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:626-821-6508
Mailing Address - Street 1:333 N SANTA ANITA AVE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-2839
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 N SANTA ANITA AVE
Practice Address - Street 2:SUITE 10
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-2839
Practice Address - Country:US
Practice Address - Phone:626-821-6508
Practice Address - Fax:626-821-6428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF10499291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB73183FMedicaid