Provider Demographics
NPI:1881626943
Name:LATARA ENTERPRISE INC.
Entity type:Organization
Organization Name:LATARA ENTERPRISE INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:LALA
Authorized Official - Middle Name:
Authorized Official - Last Name:VARTANIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-623-9301
Mailing Address - Street 1:1716 W HOLT AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-3333
Mailing Address - Country:US
Mailing Address - Phone:909-623-9301
Mailing Address - Fax:909-623-9306
Practice Address - Street 1:1716 W HOLT AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-3333
Practice Address - Country:US
Practice Address - Phone:909-623-9301
Practice Address - Fax:909-623-9306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF 489291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAX058428OtherPTAN
CA05D0642889OtherCLIA NUMBER
CALAB42889FMedicaid