Provider Demographics
NPI:1699085290
Name:HISTOPATHOLOGY SERVICES INC
Entity type:Organization
Organization Name:HISTOPATHOLOGY SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:KHODADAD
Authorized Official - Middle Name:
Authorized Official - Last Name:MEHRAEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-415-2535
Mailing Address - Street 1:15012 RED HILL AVENUE
Mailing Address - Street 2:SUITE 8H
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780
Mailing Address - Country:US
Mailing Address - Phone:949-415-2535
Mailing Address - Fax:
Practice Address - Street 1:15012 RED HILL AVE
Practice Address - Street 2:SUITE 8H
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6524
Practice Address - Country:US
Practice Address - Phone:949-415-2535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-15
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA339775OtherCLF
CA05D2009046OtherCLIA