Provider Demographics
NPI:1992887814
Name:ASHLEY CLINICAL DIAGNOSTIC LAB
Entity type:Organization
Organization Name:ASHLEY CLINICAL DIAGNOSTIC LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MADHU
Authorized Official - Middle Name:B
Authorized Official - Last Name:BANSAL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:323-478-0801
Mailing Address - Street 1:5542 N FIGUEROA ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-4120
Mailing Address - Country:US
Mailing Address - Phone:323-478-0801
Mailing Address - Fax:323-259-1007
Practice Address - Street 1:5542 N FIGUEROA ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-4120
Practice Address - Country:US
Practice Address - Phone:323-478-0801
Practice Address - Fax:323-259-1007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB587410FMedicaid
CALAB587410FMedicaid