Provider Demographics
NPI:1972873305
Name:MS DIAGNOSTIC LABORATORY LLC
Entity Type:Organization
Organization Name:MS DIAGNOSTIC LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LABORATORY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MONTANO
Authorized Official - Middle Name:DELEON
Authorized Official - Last Name:GERONIMO
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:626-840-2870
Mailing Address - Street 1:1928 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-3408
Mailing Address - Country:US
Mailing Address - Phone:626-840-2870
Mailing Address - Fax:626-445-4612
Practice Address - Street 1:1928 E CENTER ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-3408
Practice Address - Country:US
Practice Address - Phone:626-840-2870
Practice Address - Fax:626-445-4612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-02
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF00341934291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D2033427Medicare PIN