Provider Demographics
NPI:1629140793
Name:HARVARD LAB & X-RAY, INC
Entity Type:Organization
Organization Name:HARVARD LAB & X-RAY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, BLD
Authorized Official - Phone:541-672-9349
Mailing Address - Street 1:1813 W HARVARD AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-2752
Mailing Address - Country:US
Mailing Address - Phone:541-440-6316
Mailing Address - Fax:541-464-4336
Practice Address - Street 1:1813 W HARVARD AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-2752
Practice Address - Country:US
Practice Address - Phone:541-440-6316
Practice Address - Fax:541-464-4336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORJ0625OtherPACIFIC SOURCE
OR0000003290OtherBLUE CROSS OF OREGON
OR166173OtherDOUGLAS COUNTY IPA
OR288032Medicaid
OR166173OtherDOUGLAS COUNTY IPA