Provider Demographics
NPI:1023253556
Name:MEDICAL DIAGNOSTIC LABORATORY LLC
Entity type:Organization
Organization Name:MEDICAL DIAGNOSTIC LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:FAUSTO
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDEZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:626-303-8674
Mailing Address - Street 1:PO BOX 7938
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-7938
Mailing Address - Country:US
Mailing Address - Phone:626-303-8674
Mailing Address - Fax:626-256-9098
Practice Address - Street 1:1330 ARROW HWY
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-5218
Practice Address - Country:US
Practice Address - Phone:626-303-8674
Practice Address - Fax:626-256-9098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-12
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05D0642547291U00000X
CACLF1817291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory