Provider Demographics
NPI:1548208440
Name:INTERPATH LABORATORY, INC.
Entity Type:Organization
Organization Name:INTERPATH LABORATORY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, BILLING OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:GOLDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANDELLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-278-4743
Mailing Address - Street 1:PO BOX 1208
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-0780
Mailing Address - Country:US
Mailing Address - Phone:541-276-6700
Mailing Address - Fax:
Practice Address - Street 1:2460 SW PERKINS AVENUE
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801
Practice Address - Country:US
Practice Address - Phone:541-276-6700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR38D0628506291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR7018906Medicaid
ORR0000WBBJQMedicare ID - Type Unspecified
ORX13078Medicare UPIN
OR7018906Medicaid