Provider Demographics
NPI:1508256041
Name:SOUTHERN IDAHO REGIONAL LABORATORY LLC
Entity Type:Organization
Organization Name:SOUTHERN IDAHO REGIONAL LABORATORY LLC
Other - Org Name:TREASURE VALLEY LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CLARRISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-755-8903
Mailing Address - Street 1:PO BOX 2693
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99220-2693
Mailing Address - Country:US
Mailing Address - Phone:509-755-8700
Mailing Address - Fax:
Practice Address - Street 1:335 SW 13TH ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-4547
Practice Address - Country:US
Practice Address - Phone:541-889-4513
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN IDAHO REGIONAL LABORATORY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID13D0646359291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805437200Medicaid
ID805437200Medicaid