Healthcare Provider Details

I. General information

NPI: 1750315008
Provider Name (Legal Business Name): CRESTVIEW CLINICAL LABORATORY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 10/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 W PUTNAM AVE
PORTERVILLE CA
93257-3321
US

IV. Provider business mailing address

460 W PUTNAM AVE
PORTERVILLE CA
93257-3321
US

V. Phone/Fax

Practice location:
  • Phone: 559-781-6975
  • Fax: 559-783-2084
Mailing address:
  • Phone: 559-781-6975
  • Fax: 559-783-2084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number05D0930808
License Number StateCA

VIII. Authorized Official

Name: ROY BERGLUND
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 559-781-6975