Provider Demographics
NPI:1790950145
Name:PATHNET LAB INSTITUTE SOUTH
Entity Type:Organization
Organization Name:PATHNET LAB INSTITUTE SOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KAYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-780-6300
Mailing Address - Street 1:7247 HAYVENHURST AVE
Mailing Address - Street 2:SUITE A3
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-2871
Mailing Address - Country:US
Mailing Address - Phone:818-780-6300
Mailing Address - Fax:818-781-2243
Practice Address - Street 1:2391 NE LOOP 410
Practice Address - Street 2:MARYMONT BUSINESS CENTRE BUILDING 3 SUITE 309
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-5600
Practice Address - Country:US
Practice Address - Phone:818-780-6300
Practice Address - Fax:818-781-2243
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PATHNET ESOTERIC LABORATORY INSTITUTE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXCOS800143291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1670200Medicaid
TX269559OtherOR MEDICAID
TX37000809OtherKY MEDICAID
TX45D0972921OtherCLIA
TX0589010OtherIOWA MEDICAID
TX404539401OtherMD MEDICAID
WY112130800Medicaid
CA404539400OtherMD MEDICAID
ALLB233CAMedicaid
TXCL8557Medicare PIN