Medical Diagnostic Laboratory LLC

Primary specialty

Clinical Medical LaboratoryTaxonomy code 291U00000X

License

CLF1817 Issued in CA

Legal business name

MEDICAL DIAGNOSTIC LABORATORY LLC

Practice address

1330 Arrow Hwy
La Verne, CA 91750-5218

Phone

(626) 303-8674

Fax

(626) 256-9098

NPI assigned

Dec 12, 2008

Last updated

Oct 8, 2013By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Fausto Mendez Jr.

Title

Managing Member

Phone

(626) 303-8674

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in CA

Enrollment records 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1229040000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1381190400000",
    "number": "1023253556",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 7938",
            "city": "LA VERNE",
            "state": "CA",
            "postal_code": "917507938",
            "telephone_number": "626-303-8674",
            "fax_number": "626-256-9098"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1330 ARROW HWY",
            "city": "LA VERNE",
            "state": "CA",
            "postal_code": "917505218",
            "telephone_number": "626-303-8674",
            "fax_number": "626-256-9098"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MEDICAL DIAGNOSTIC LABORATORY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-12-12",
        "last_updated": "2013-10-08",
        "status": "A",
        "authorized_official_last_name": "MENDEZ",
        "authorized_official_first_name": "FAUSTO",
        "authorized_official_title_or_position": "MANAGING MEMBER",
        "authorized_official_telephone_number": "626-303-8674",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "CA",
            "license": "05D0642547",
            "primary": false
        },
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "CA",
            "license": "CLF1817",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• May Medical Management Corporation
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• Amber Meeks, COTA/L
• Jennifer Nicole Melendrez
• Chyna Mendoza

• Clinical Medical Laboratory in La Verne, CA
• Providers in La Verne, CA by specialty
• Clinical Medical Laboratory in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 8, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.