Provider Demographics
NPI:1962546176
Name:MATIAS CLINICAL LABORATORY INC
Entity type:Organization
Organization Name:MATIAS CLINICAL LABORATORY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EMILIO
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLARBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-813-3800
Mailing Address - Street 1:14411 PALMROSE STREET
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706
Mailing Address - Country:US
Mailing Address - Phone:626-813-3800
Mailing Address - Fax:626-813-3808
Practice Address - Street 1:14411 PALMROSE STREET
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706
Practice Address - Country:US
Practice Address - Phone:626-813-3800
Practice Address - Fax:626-337-2037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB95741FMedicaid