Provider Demographics
NPI:1861413023
Name:DIAGNOSTIC LABORATORY SCIENCE, INC
Entity type:Organization
Organization Name:DIAGNOSTIC LABORATORY SCIENCE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:HISERODT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-743-5253
Mailing Address - Street 1:7711 GARDEN GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92841-4207
Mailing Address - Country:US
Mailing Address - Phone:310-787-7022
Mailing Address - Fax:310-787-7010
Practice Address - Street 1:DIAGNOSTIC LABOATORY SCIENCE, INC.
Practice Address - Street 2:7711 GARDEN GROVE BLVD
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92841-4207
Practice Address - Country:US
Practice Address - Phone:310-787-7022
Practice Address - Fax:310-787-7010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF 11540291U00000X
CACLF00011540291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB57076FMedicaid
CA1861413023Medicaid
CA1861413023Medicaid