Provider Demographics
NPI:1861706897
Name:LINCOLN CLINICAL DIAGNOSTIC LABORATORY
Entity type:Organization
Organization Name:LINCOLN CLINICAL DIAGNOSTIC LABORATORY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-635-2430
Mailing Address - Street 1:520 N BROOKHURST ST
Mailing Address - Street 2:SUITE #121
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-5227
Mailing Address - Country:US
Mailing Address - Phone:714-635-2430
Mailing Address - Fax:714-635-4138
Practice Address - Street 1:520 N BROOKHURST ST
Practice Address - Street 2:SUITE #121
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-5227
Practice Address - Country:US
Practice Address - Phone:714-635-2430
Practice Address - Fax:714-635-4138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-02
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF00339715291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D2007832OtherCLIA ID NUMBER
CA20A5179OtherLICENSE
CACLF00339715OtherLAB LICENSE