Provider Demographics
NPI:1679686646
Name:SPECTRA CLINICAL LABORATORIES, INC
Entity type:Organization
Organization Name:SPECTRA CLINICAL LABORATORIES, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:QUIMBY-JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-545-8738
Mailing Address - Street 1:PO BOX 755
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-0755
Mailing Address - Country:US
Mailing Address - Phone:562-776-8440
Mailing Address - Fax:562-776-8070
Practice Address - Street 1:5160 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2101
Practice Address - Country:US
Practice Address - Phone:562-776-8440
Practice Address - Fax:562-776-8070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF 10042291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAX558836OtherMEDICARE PTAN #
CALAB58836FMedicaid