Provider Demographics
NPI:1750315008
Name:CRESTVIEW CLINICAL LABORATORY
Entity Type:Organization
Organization Name:CRESTVIEW CLINICAL LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGLUND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-781-6975
Mailing Address - Street 1:460 W PUTNAM AVE
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257-3321
Mailing Address - Country:US
Mailing Address - Phone:559-781-6975
Mailing Address - Fax:559-783-2084
Practice Address - Street 1:460 W PUTNAM AVE
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-3321
Practice Address - Country:US
Practice Address - Phone:559-781-6975
Practice Address - Fax:559-783-2084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05D0930808291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB30808FMedicaid
CALAB30808FMedicaid