Provider Demographics
NPI:1194416628
Name:PERSONALIZED PEDIATRIC LABORATORIES LLC
Entity type:Organization
Organization Name:PERSONALIZED PEDIATRIC LABORATORIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANALO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-253-2923
Mailing Address - Street 1:1744 BERKELEY ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-4105
Mailing Address - Country:US
Mailing Address - Phone:725-240-0608
Mailing Address - Fax:888-356-3518
Practice Address - Street 1:1744 BERKELEY ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-4105
Practice Address - Country:US
Practice Address - Phone:725-240-0608
Practice Address - Fax:888-356-3518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-16
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory