Community Health Clinical Laboratory LLC

Primary specialty

Clinical Medical LaboratoryTaxonomy code 291U00000X

Legal business name

COMMUNITY HEALTH CLINICAL LABORATORY LLC

Practice address

150 Tejas Place
BLDG. B Suite a
Nipomo, CA 93444

Phone

(805) 338-0460

NPI assigned

Mar 18, 2020

Last updated

Mar 19, 2020By 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

Alexandre Feoktistov

Title

President

Phone

(805) 338-0460

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in CA

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

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

{
    "created_epoch": "1584489600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1584576000000",
    "number": "1679109995",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "150 TEJAS PLACE",
            "address_2": "BLDG. B SUITE A",
            "city": "NIPOMO",
            "state": "CA",
            "postal_code": "93444",
            "telephone_number": "805-338-0460"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "150 TEJAS PLACE",
            "address_2": "BLDG. B SUITE A",
            "city": "NIPOMO",
            "state": "CA",
            "postal_code": "93444",
            "telephone_number": "805-338-0460"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY HEALTH CLINICAL LABORATORY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-03-18",
        "last_updated": "2020-03-19",
        "certification_date": "2020-03-19",
        "status": "A",
        "authorized_official_last_name": "FEOKTISTOV",
        "authorized_official_first_name": "ALEXANDRE",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "805-338-0460"
    },
    "taxonomies": [
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Barbara Ann Cosio, RDN

• Clinical Medical Laboratory in Nipomo, CA
• Providers in Nipomo, 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 Mar 19, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.