Basic Information
| Provider Information | |||||||||
| NPI: | 1639386964 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL LABORATORY SERVICES MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10076 | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914100076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055788300 | ||||||||
| FaxNumber: | 8055783911 | ||||||||
| Practice Location | |||||||||
| Address1: | 25470 MEDICAL CENTER DRIVE | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | MURRIETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9518349025 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 06/03/2008 | ||||||||
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| AuthorizedOfficialLastName: | HOLBURT | ||||||||
| AuthorizedOfficialFirstName: | ERNEST | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9518349025 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 00G471370 | 05 | CA | MEDICAID | GR0092911 | 05 | CA | MEDICAID |