Provider Demographics
NPI:1639386964
Name:MEDICAL LABORATORY SERVICES MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:MEDICAL LABORATORY SERVICES MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLBURT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-834-9020
Mailing Address - Street 1:PO BOX 2740
Mailing Address - Street 2:
Mailing Address - City:FALLBROOK
Mailing Address - State:CA
Mailing Address - Zip Code:92088-2740
Mailing Address - Country:US
Mailing Address - Phone:805-250-9233
Mailing Address - Fax:805-578-3911
Practice Address - Street 1:40663 MURRIETA HOT SPRINGS RD STE C1
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-9015
Practice Address - Country:US
Practice Address - Phone:951-834-9020
Practice Address - Fax:951-834-9026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G471370Medicaid
CAGR0092911Medicaid
CA00G471370Medicaid
CAZZZ59089ZMedicare PIN