Provider Demographics
NPI:1851422240
Name:COMMUNITY DIAGNOSTIC LABORATORY
Entity Type:Organization
Organization Name:COMMUNITY DIAGNOSTIC LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-305-5709
Mailing Address - Street 1:1941 WALKER AVE
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-4846
Mailing Address - Country:US
Mailing Address - Phone:626-305-5709
Mailing Address - Fax:
Practice Address - Street 1:1941 WALKER AVE
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-4846
Practice Address - Country:US
Practice Address - Phone:626-305-5709
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF10748291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D088753AMedicare ID - Type UnspecifiedMEDICARE PROVIDER