Provider Demographics
NPI:1578452215
Name:MEDICAL DIAGNOSTIC AND PROGNOSTIC LABORATORY
Entity type:Organization
Organization Name:MEDICAL DIAGNOSTIC AND PROGNOSTIC LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KIAT
Authorized Official - Middle Name:YEONG
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-567-9213
Mailing Address - Street 1:14 STALLION RD
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-5257
Mailing Address - Country:US
Mailing Address - Phone:310-567-9213
Mailing Address - Fax:
Practice Address - Street 1:4117 SOUTH ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-1043
Practice Address - Country:US
Practice Address - Phone:562-723-6732
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-30
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory