Provider Demographics
NPI:1285645226
Name:CRESTVIEW CLINICAL LABORATORY
Entity Type:Organization
Organization Name:CRESTVIEW CLINICAL LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LEONA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGLUND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-877-1361
Mailing Address - Street 1:1471 S RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-7703
Mailing Address - Country:US
Mailing Address - Phone:909-877-1361
Mailing Address - Fax:
Practice Address - Street 1:1471 S RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-7703
Practice Address - Country:US
Practice Address - Phone:909-877-1361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
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
CALAB64416FOtherPIN NUMBER