Provider Demographics
NPI:1669142279
Name:BUENA VISTA LABS LLC
Entity type:Organization
Organization Name:BUENA VISTA LABS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHERITA
Authorized Official - Middle Name:N
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-993-2040
Mailing Address - Street 1:759 CHIEF JUSTICE CUSHING HWY STE 359
Mailing Address - Street 2:
Mailing Address - City:COHASSET
Mailing Address - State:MA
Mailing Address - Zip Code:02025-2115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:954-990-6305
Practice Address - Street 1:25K OLYMPIA AVE
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-7245
Practice Address - Country:US
Practice Address - Phone:781-904-3130
Practice Address - Fax:954-990-6305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-15
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA22D2227755OtherCLIA