Provider Demographics
NPI:1205946316
Name:CERRITOS REFERENCE LABORATORIES INC
Entity type:Organization
Organization Name:CERRITOS REFERENCE LABORATORIES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ISSAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KABBANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-674-5938
Mailing Address - Street 1:3188 AIRWAY AVE STE D
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-4652
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3188 AIRWAY AVE STE D
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4652
Practice Address - Country:US
Practice Address - Phone:949-674-5938
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05D0955926291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB55926FMedicaid