Provider Demographics
NPI:1992866263
Name:CENTRAL REFERENCE LABORATORY INC
Entity Type:Organization
Organization Name:CENTRAL REFERENCE LABORATORY INC
Other - Org Name:DIAMOND REFERENCE LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ABBAS
Authorized Official - Middle Name:
Authorized Official - Last Name:RAJAEE
Authorized Official - Suffix:
Authorized Official - Credentials:MSC,JD
Authorized Official - Phone:9090-861-6966
Mailing Address - Street 1:1470 S.VALLEY VISTA DR
Mailing Address - Street 2:100
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-3903
Mailing Address - Country:US
Mailing Address - Phone:909-861-6966
Mailing Address - Fax:909-860-6396
Practice Address - Street 1:1470 S.VALLEY VISTA DR
Practice Address - Street 2:100
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-3903
Practice Address - Country:US
Practice Address - Phone:909-861-6966
Practice Address - Fax:909-860-6396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF4032291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACLF4032OtherLAB
CALAB04032FMedicaid
CAX558264Medicare ID - Type UnspecifiedLAB