Provider Demographics
NPI:1730358698
Name:CANDU LAB SERVICES
Entity type:Organization
Organization Name:CANDU LAB SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:STIVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-289-2351
Mailing Address - Street 1:15904 STRATHERN ST
Mailing Address - Street 2:SUITE 19
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-1314
Mailing Address - Country:US
Mailing Address - Phone:719-289-2351
Mailing Address - Fax:
Practice Address - Street 1:400 S UNION AVE
Practice Address - Street 2:SUITE B
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3431
Practice Address - Country:US
Practice Address - Phone:719-289-2351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR-23150207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COA01926Medicare UPIN