Provider Demographics
NPI:1073682506
Name:VENTANA WELLNESS, PC
Entity Type:Organization
Organization Name:VENTANA WELLNESS, PC
Other - Org Name:ROGUE CLINICAL LABORATORIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN ES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-842-7134
Mailing Address - Street 1:3156 STATE ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8450
Mailing Address - Country:US
Mailing Address - Phone:541-773-9772
Mailing Address - Fax:541-773-1113
Practice Address - Street 1:3156 STATE ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:541-773-9772
Practice Address - Fax:541-773-1113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR136085Medicare PIN