Basic Information
| Provider Information | |||||||||
| NPI: | 1316356397 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SCADRF | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25332 PACIFICA AVE | ||||||||
| Address2: | |||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926913843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495882190 | ||||||||
| FaxNumber: | 9495882199 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 HOLLAND STE 101 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926182568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495882190 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2014 | ||||||||
| LastUpdateDate: | 08/05/2014 | ||||||||
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| AuthorizedOfficialLastName: | YARTER | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9495882190 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X | 05D2065269 | CA | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 291U00000X | CA | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 05D2065269 | 01 | CA | CLIA | OTHER |