Provider Demographics
NPI:1457405540
Name:MN CLINICAL LABORATORY INC
Entity Type:Organization
Organization Name:MN CLINICAL LABORATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOON
Authorized Official - Middle Name:SUECK
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MEDICAL DOCTOR MD
Authorized Official - Phone:310-429-8711
Mailing Address - Street 1:4712 ADMIRALTY WAY
Mailing Address - Street 2:# 1010
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6905
Mailing Address - Country:US
Mailing Address - Phone:310-429-8711
Mailing Address - Fax:310-577-7560
Practice Address - Street 1:1327 S MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-4150
Practice Address - Country:US
Practice Address - Phone:626-303-8674
Practice Address - Fax:310-577-7560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF1817291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95438506OtherCHOC HEALTH ALLIANCE
CALAB72547GOtherCAL OPTIMA DIRECT
CALAB72547GMedicaid
CA95438506OtherCHOC HEALTH ALLIANCE