Provider Demographics
NPI:1992895643
Name:MEGAMED CLINICAL LABORATORIES INC
Entity type:Organization
Organization Name:MEGAMED CLINICAL LABORATORIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAPOUR
Authorized Official - Middle Name:
Authorized Official - Last Name:MOTAMEDI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:818-654-0632
Mailing Address - Street 1:7302 CANBY AVE
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-3010
Mailing Address - Country:US
Mailing Address - Phone:818-654-0632
Mailing Address - Fax:818-654-0634
Practice Address - Street 1:7302 CANBY AVE
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-3010
Practice Address - Country:US
Practice Address - Phone:818-654-0632
Practice Address - Fax:818-654-0634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB69790GMedicaid
CAZZZ64202ZOtherBLUE SHIELD
CACLF011639OtherSTATE LICENSE
CALAB69790GMedicaid