Provider Demographics
NPI:1700938255
Name:HAVENSIGHT MEDICAL LABORATORY INC
Entity Type:Organization
Organization Name:HAVENSIGHT MEDICAL LABORATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KIT ALIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:340-774-5515
Mailing Address - Street 1:PO BOX 502934
Mailing Address - Street 2:9003 HAVENSIGHT SUITE 312
Mailing Address - City:ST THOMAS
Mailing Address - State:VI
Mailing Address - Zip Code:00805
Mailing Address - Country:US
Mailing Address - Phone:340-774-5515
Mailing Address - Fax:340-774-1251
Practice Address - Street 1:9003 HAVENSIGHT
Practice Address - Street 2:SUITE 312
Practice Address - City:ST THOMAS
Practice Address - State:VI
Practice Address - Zip Code:00802
Practice Address - Country:US
Practice Address - Phone:340-774-5515
Practice Address - Fax:340-774-1251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
VI30912Medicare ID - Type Unspecified