Provider Demographics
NPI:1639215767
Name:EL DORADO COUNTY PUBLIC HEALTH LABORATORY
Entity Type:Organization
Organization Name:EL DORADO COUNTY PUBLIC HEALTH LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DEATHERAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-621-6115
Mailing Address - Street 1:931 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-4543
Mailing Address - Country:US
Mailing Address - Phone:530-621-6115
Mailing Address - Fax:530-642-8531
Practice Address - Street 1:931 SPRING ST
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-4543
Practice Address - Country:US
Practice Address - Phone:530-621-6115
Practice Address - Fax:530-642-8531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB58853FMedicaid