Provider Demographics
NPI:1558713313
Name:ENVISION HEALTH LAB, LLC
Entity Type:Organization
Organization Name:ENVISION HEALTH LAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VINCE
Authorized Official - Middle Name:
Authorized Official - Last Name:OJEDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-717-8270
Mailing Address - Street 1:1716 CORPORATE XING
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-3743
Mailing Address - Country:US
Mailing Address - Phone:618-717-8270
Mailing Address - Fax:618-726-2030
Practice Address - Street 1:1716 CORPORATE XING
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-3743
Practice Address - Country:US
Practice Address - Phone:618-717-8270
Practice Address - Fax:618-726-2030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-05
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.100502291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory