Provider Demographics
NPI:1457739559
Name:NORTHWEST MEDICAL DIAGNOSTIC LABORATORY
Entity Type:Organization
Organization Name:NORTHWEST MEDICAL DIAGNOSTIC LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:LIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MLT
Authorized Official - Phone:360-442-4129
Mailing Address - Street 1:1003 FIR ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632
Mailing Address - Country:US
Mailing Address - Phone:360-442-4129
Mailing Address - Fax:360-442-4130
Practice Address - Street 1:1003 FIR ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2526
Practice Address - Country:US
Practice Address - Phone:360-442-4129
Practice Address - Fax:360-442-4130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-11
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA50D2098207291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory