Provider Demographics
NPI:1528376688
Name:MEDVISTA LABORATORY INC
Entity Type:Organization
Organization Name:MEDVISTA LABORATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MWESIGWA
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE
Authorized Official - Phone:773-218-1004
Mailing Address - Street 1:3029 E 92ND ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-4500
Mailing Address - Country:US
Mailing Address - Phone:773-218-1004
Mailing Address - Fax:773-762-4333
Practice Address - Street 1:3138 W CERMAK RD
Practice Address - Street 2:SUITE 103
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-3306
Practice Address - Country:US
Practice Address - Phone:773-762-4331
Practice Address - Fax:773-762-4333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14D2011212291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory