Provider Demographics
NPI:1760706576
Name:SDXRAY & LAB
Entity Type:Organization
Organization Name:SDXRAY & LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KITTY
Authorized Official - Middle Name:
Authorized Official - Last Name:WEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-525-5647
Mailing Address - Street 1:PO BOX 4554
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-0554
Mailing Address - Country:US
Mailing Address - Phone:909-594-6469
Mailing Address - Fax:909-348-8166
Practice Address - Street 1:3220 S BREA CANYON RD
Practice Address - Street 2:STE B
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-3481
Practice Address - Country:US
Practice Address - Phone:909-594-6469
Practice Address - Fax:909-348-8166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-23
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALC20080000366293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory