Healthcare Provider Details

I. General information

NPI: 1669142279
Provider Name (Legal Business Name): BUENA VISTA LABS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2021
Last Update Date: 01/17/2022
Certification Date: 01/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25K OLYMPIA AVE
WOBURN MA
01801-7245
US

IV. Provider business mailing address

759 CHIEF JUSTICE CUSHING HWY STE 359
COHASSET MA
02025-2115
US

V. Phone/Fax

Practice location:
  • Phone: 781-904-3130
  • Fax: 954-990-6305
Mailing address:
  • Phone:
  • Fax: 954-990-6305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SHERITA N CHANG
Title or Position: MANAGER
Credential:
Phone: 954-993-2040