Provider Demographics
NPI:1992924146
Name:MEDIPACE POL
Entity type:Organization
Organization Name:MEDIPACE POL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MERCEDES
Authorized Official - Middle Name:
Authorized Official - Last Name:BIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-550-6242
Mailing Address - Street 1:9033 WILSHIRE BLVD
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-1837
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9033 WILSHIRE BLVD
Practice Address - Street 2:5TH FLOOR
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1837
Practice Address - Country:US
Practice Address - Phone:310-550-6240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF4840291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB54371FMedicaid