MEDICARE: MEDVISTA LABORATORY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory	14D2011212	IL

General Provider Information

NPI Number	:	1528376688
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDVISTA LABORATORY INC

Provider Business Mailing Address
First Line	:	3029 E 92ND ST
Second Line	:	SUITE 1
City	:	CHICAGO
State	:	IL
Zip	:	60617-4500
Country	:	US
Telephone Number	:	773-218-1004
Fax Number	:	773-762-4333

Provider Business Practice Location Address
First Line	:	3138 W CERMAK RD
Second Line	:	SUITE 103
City	:	CHICAGO
State	:	IL
Zip	:	60623-3306
Country	:	US
Telephone Number	:	773-762-4331
Fax Number	:	773-762-4333

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOHN MWESIGWA
Credential	:	NURSE
Telephone Number	:	773-218-1004

Provider Enumeration Date	:	09/22/2010
Last Update Date	:	09/22/2010

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