Provider Demographics
NPI:1639588205
Name:JOHN BILDER FUND BILLINGSWORTH LAB
Entity Type:Organization
Organization Name:JOHN BILDER FUND BILLINGSWORTH LAB
Other - Org Name:JOHN BILDER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DNA LAB BURN UNIT CREMATION
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN SUE
Authorized Official - Middle Name:S
Authorized Official - Last Name:CROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:562-536-6391
Mailing Address - Street 1:7202 GREENLEAF AVE
Mailing Address - Street 2:13303 PHILADELPHIA ST
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90602-1312
Mailing Address - Country:US
Mailing Address - Phone:562-536-6391
Mailing Address - Fax:
Practice Address - Street 1:7202 GREENLEAF AVE
Practice Address - Street 2:13303 PHILADELPHIA ST
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90602-1312
Practice Address - Country:US
Practice Address - Phone:562-536-6391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-08
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC004885460292200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes292200000XLaboratoriesDental Laboratory