Provider Demographics
NPI:1366653800
Name:WESTERN PATHOLOGY ASSOCIATES LLC
Entity Type:Organization
Organization Name:WESTERN PATHOLOGY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CELENE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:MHRTD
Authorized Official - Phone:208-233-3794
Mailing Address - Street 1:PO BOX 2537
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83206-2537
Mailing Address - Country:US
Mailing Address - Phone:208-233-3794
Mailing Address - Fax:208-233-3795
Practice Address - Street 1:1950 E CLARK ST STE D
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3314
Practice Address - Country:US
Practice Address - Phone:208-233-3794
Practice Address - Fax:208-233-3795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID207ZP0102X291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002467700Medicaid
ID002467700Medicaid
IDU74298Medicare UPIN