Provider Demographics
NPI:1790550523
Name:MAMMOTH PATH SOLUTION LLC
Entity Type:Organization
Organization Name:MAMMOTH PATH SOLUTION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-332-0669
Mailing Address - Street 1:20505 CRESCENT BAY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-8825
Mailing Address - Country:US
Mailing Address - Phone:949-317-0345
Mailing Address - Fax:949-446-9141
Practice Address - Street 1:20505 CRESCENT BAY DR STE A2
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-8825
Practice Address - Country:US
Practice Address - Phone:949-317-0345
Practice Address - Fax:949-446-9141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-21
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory