Provider Demographics
NPI:1255400065
Name:MED TECH CLINICAL LABORATORY,INC
Entity type:Organization
Organization Name:MED TECH CLINICAL LABORATORY,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BIJAN
Authorized Official - Middle Name:
Authorized Official - Last Name:YASHAYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-768-0701
Mailing Address - Street 1:438 GANTTOWN RD
Mailing Address - Street 2:SUITE B-8
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-2341
Mailing Address - Country:US
Mailing Address - Phone:856-768-0701
Mailing Address - Fax:856-768-0702
Practice Address - Street 1:175 CROSS KEYS RD
Practice Address - Street 2:SUITE 203
Practice Address - City:BERLIN
Practice Address - State:NJ
Practice Address - Zip Code:08009-9263
Practice Address - Country:US
Practice Address - Phone:856-768-0701
Practice Address - Fax:856-768-0702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0000855291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ059378Medicare ID - Type Unspecified