Provider Demographics
NPI:1124517784
Name:ULTRA MEDICAL LAB INC
Entity type:Organization
Organization Name:ULTRA MEDICAL LAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:CHIH FANG
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:424-404-3317
Mailing Address - Street 1:3860 DEL AMO BLVD STE 402
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-2196
Mailing Address - Country:US
Mailing Address - Phone:424-404-3317
Mailing Address - Fax:424-652-5520
Practice Address - Street 1:3860 DEL AMO BLVD STE 402
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-2196
Practice Address - Country:US
Practice Address - Phone:424-404-3317
Practice Address - Fax:424-652-5520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory