Provider Demographics
NPI:1407813777
Name:HISTO-PATH TECHNICAL SPECIALTIES, INC
Entity type:Organization
Organization Name:HISTO-PATH TECHNICAL SPECIALTIES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, BILLING MGR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-522-8240
Mailing Address - Street 1:PO BOX 4978
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95352-4978
Mailing Address - Country:US
Mailing Address - Phone:209-575-4575
Mailing Address - Fax:209-575-4598
Practice Address - Street 1:4847 KIERNAN CT STE 1
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CA
Practice Address - Zip Code:95368-9524
Practice Address - Country:US
Practice Address - Phone:209-575-4575
Practice Address - Fax:209-575-4598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No246QH0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyHistologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMMM00013MMedicare PIN