Provider Demographics
NPI:1891907150
Name:ALFRED J REYNAUD
Entity Type:Organization
Organization Name:ALFRED J REYNAUD
Other - Org Name:MEDICAL SPECIALTY LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:J
Authorized Official - Last Name:REYNAUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-839-4829
Mailing Address - Street 1:PO BOX 27146
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94127
Mailing Address - Country:US
Mailing Address - Phone:510-839-4829
Mailing Address - Fax:
Practice Address - Street 1:2929 SUMMIT ST
Practice Address - Street 2:#208
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609
Practice Address - Country:US
Practice Address - Phone:510-839-4829
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF2773291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ59174ZMedicaid
CAZZZ59174ZMedicaid