Provider Demographics
NPI:1801044508
Name:MEDICAL SCIENCE LABORATORY INC
Entity Type:Organization
Organization Name:MEDICAL SCIENCE LABORATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KAMBAKSH
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVAKOLI
Authorized Official - Suffix:
Authorized Official - Credentials:CHS
Authorized Official - Phone:310-360-0066
Mailing Address - Street 1:432 S SAN VICENTE BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-4183
Mailing Address - Country:US
Mailing Address - Phone:310-360-0066
Mailing Address - Fax:310-360-0302
Practice Address - Street 1:432 S SAN VICENTE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4192
Practice Address - Country:US
Practice Address - Phone:310-360-0066
Practice Address - Fax:310-360-0302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-05
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05D1082642291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory