Provider Demographics
NPI:1801869524
Name:PACIFIC AVENUE MEDICAL LABORATORY, INC.
Entity type:Organization
Organization Name:PACIFIC AVENUE MEDICAL LABORATORY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY MANAGER/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:
Authorized Official - Last Name:OWYANG
Authorized Official - Suffix:
Authorized Official - Credentials:CLS
Authorized Official - Phone:415-982-8828
Mailing Address - Street 1:728 PACIFIC AVE
Mailing Address - Street 2:SUITE #401
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94133-4457
Mailing Address - Country:US
Mailing Address - Phone:415-982-8828
Mailing Address - Fax:415-982-8831
Practice Address - Street 1:728 PACIFIC AVE
Practice Address - Street 2:SUITE #401
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94133-4457
Practice Address - Country:US
Practice Address - Phone:415-982-8828
Practice Address - Fax:415-982-8831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF 4446291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB58442FMedicaid
CAZZZ58442ZMedicare ID - Type UnspecifiedMEDICARE
CALAB58442FMedicaid