Provider Demographics
NPI:1649544685
Name:VISTA PATHOLOGY LABORATORY, LLC
Entity type:Organization
Organization Name:VISTA PATHOLOGY LABORATORY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARI
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-770-4559
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-0071
Mailing Address - Country:US
Mailing Address - Phone:541-770-4559
Mailing Address - Fax:541-770-4511
Practice Address - Street 1:94220 4TH ST
Practice Address - Street 2:
Practice Address - City:GOLD BEACH
Practice Address - State:OR
Practice Address - Zip Code:97444-7756
Practice Address - Country:US
Practice Address - Phone:800-445-8085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-07
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR38D2036013OtherCLIA