Healthcare Provider Details

I. General information

NPI: 1588600456
Provider Name (Legal Business Name): MIRAVISTA DIAGNOSTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4444 DECATUR BLVD SUITE 300
INDIANAPOLIS IN
46241-9537
US

IV. Provider business mailing address

4444 DECATUR BLVD SUITE 300
INDIANAPOLIS IN
46241-9537
US

V. Phone/Fax

Practice location:
  • Phone: 317-856-2681
  • Fax: 317-856-3685
Mailing address:
  • Phone: 317-856-2681
  • Fax: 317-856-3685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateIN

VIII. Authorized Official

Name: MR. LAWRENCE J WHEAT
Title or Position: PRESIDENT AND DIRECTOR
Credential: M.D.
Phone: 317-856-2681