Provider Demographics
NPI:1316073349
Name:SAN GABRIEL CLINICAL LABORATORIES
Entity type:Organization
Organization Name:SAN GABRIEL CLINICAL LABORATORIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MONTANO
Authorized Official - Middle Name:DELEON
Authorized Official - Last Name:GERONIMO
Authorized Official - Suffix:JR
Authorized Official - Credentials:CPT1
Authorized Official - Phone:626-281-8190
Mailing Address - Street 1:201 S MISSION DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-1164
Mailing Address - Country:US
Mailing Address - Phone:626-281-8190
Mailing Address - Fax:626-281-8129
Practice Address - Street 1:201 S MISSION DR
Practice Address - Street 2:SUITE 120
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-1164
Practice Address - Country:US
Practice Address - Phone:626-281-8190
Practice Address - Fax:626-281-8129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF335013291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory