1093912297 NPI number — SHASTA MEDICAL LAB

Table of content: MS. TERESE WUNDERLICH L.M.T. (NPI 1679107387)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093912297 NPI number — SHASTA MEDICAL LAB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHASTA MEDICAL LAB
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093912297
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1555 EAST ST
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
REDDING
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96001-1153
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-242-4694
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1555 EAST ST
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
REDDING
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96001-1153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-242-4694
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
SHAWNA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
BILLING
Authorized Official Telephone Number:
530-244-6716

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00299430 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: LAB66820F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com