Provider Demographics
NPI:1760557375
Name:CASCADE MEDICAL TESTING LAB, INC.
Entity Type:Organization
Organization Name:CASCADE MEDICAL TESTING LAB, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:DEJONGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-956-6090
Mailing Address - Street 1:PO BOX 88247
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49518-0247
Mailing Address - Country:US
Mailing Address - Phone:616-734-0335
Mailing Address - Fax:616-949-8540
Practice Address - Street 1:2251 E PARIS AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2431
Practice Address - Country:US
Practice Address - Phone:616-956-6090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROBERT DEJONGE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-21
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION76460Medicare PIN