Provider Demographics
NPI:1669135661
Name:SOURCE BIOSCIENCE INC
Entity type:Organization
Organization Name:SOURCE BIOSCIENCE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LAB CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:YU
Authorized Official - Suffix:
Authorized Official - Credentials:MS, MBA, MLS (ASCP)
Authorized Official - Phone:626-236-2706
Mailing Address - Street 1:6696 MESA RIDGE RD STE B
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-2950
Mailing Address - Country:US
Mailing Address - Phone:858-344-7993
Mailing Address - Fax:
Practice Address - Street 1:6696 MESA RIDGE RD STE B
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-2950
Practice Address - Country:US
Practice Address - Phone:858-344-7993
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-16
Last Update Date:2021-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory