Provider Demographics
NPI:1659063402
Name:SOVEREIGNDARITY LABORATION GROUP, LLC
Entity Type:Organization
Organization Name:SOVEREIGNDARITY LABORATION GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LATRICE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-903-4015
Mailing Address - Street 1:18017 CHATSWORTH ST # 255
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-5608
Mailing Address - Country:US
Mailing Address - Phone:818-903-4015
Mailing Address - Fax:
Practice Address - Street 1:14521 BIRCHWOOD CT
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-1469
Practice Address - Country:US
Practice Address - Phone:818-903-4015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-22
Last Update Date:2023-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Single Specialty