Provider Demographics
NPI:1942402672
Name:COUNTY OF MERCED
Entity Type:Organization
Organization Name:COUNTY OF MERCED
Other - Org Name:MERCED COUNTY LAB
Other - Org Type:Other Name
Authorized Official - Title/Position:FISCAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:HAVENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-381-1200
Mailing Address - Street 1:260 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-6216
Mailing Address - Country:US
Mailing Address - Phone:209-381-1200
Mailing Address - Fax:209-381-1215
Practice Address - Street 1:260 E 15TH ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-6216
Practice Address - Country:US
Practice Address - Phone:209-381-1200
Practice Address - Fax:209-381-1215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB00866FMedicaid
CALAB00866FMedicaid