Provider Demographics
NPI:1679015788
Name:AVICENNA LABORATORY DIAGNOSTICS, INC.
Entity Type:Organization
Organization Name:AVICENNA LABORATORY DIAGNOSTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PUNZALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-201-9893
Mailing Address - Street 1:20011 VENTURA BLVD STE 1002A
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-2633
Mailing Address - Country:US
Mailing Address - Phone:818-914-5597
Mailing Address - Fax:818-914-5596
Practice Address - Street 1:20011 VENTURA BLVD STE 1002A
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-2633
Practice Address - Country:US
Practice Address - Phone:818-914-5597
Practice Address - Fax:818-914-5596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-07
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF 00349262291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory