Provider Demographics
NPI:1154557213
Name:CRESTVIEW CLINICAL LABORATORY
Entity type:Organization
Organization Name:CRESTVIEW CLINICAL LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEONA
Authorized Official - Middle Name:JUNE
Authorized Official - Last Name:BERGLUND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-877-1361
Mailing Address - Street 1:1471 S RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-7703
Mailing Address - Country:US
Mailing Address - Phone:909-877-1361
Mailing Address - Fax:909-877-0854
Practice Address - Street 1:1471 S RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-7703
Practice Address - Country:US
Practice Address - Phone:909-877-1361
Practice Address - Fax:909-877-0854
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRESTVIEW CONVALESCENT HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-03
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF 11381291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory