Provider Demographics
NPI:1639481674
Name:PATHOLOGISTS REGIONAL LABORATORY
Entity Type:Organization
Organization Name:PATHOLOGISTS REGIONAL LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:CLIFTON
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-746-0516
Mailing Address - Street 1:415 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2431
Mailing Address - Country:US
Mailing Address - Phone:208-746-0516
Mailing Address - Fax:208-798-3607
Practice Address - Street 1:1225 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2829
Practice Address - Country:US
Practice Address - Phone:509-758-4652
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1009693Medicaid
WAG000355300Medicare PIN