Provider Demographics
NPI:1013169499
Name:MESA CLINICAL LABORATORIES, PC
Entity Type:Organization
Organization Name:MESA CLINICAL LABORATORIES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:V
Authorized Official - Last Name:MESA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:503-257-5568
Mailing Address - Street 1:10300 NE HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-3831
Mailing Address - Country:US
Mailing Address - Phone:503-257-5567
Mailing Address - Fax:
Practice Address - Street 1:10300 NE HANCOCK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-3831
Practice Address - Country:US
Practice Address - Phone:503-257-5567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-16
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR38D1062236291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR146078Medicare PIN