Healthcare Provider Details

I. General information

NPI: 1548208440
Provider Name (Legal Business Name): INTERPATH LABORATORY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 12/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 SW PERKINS AVENUE
PENDLETON OR
97801
US

IV. Provider business mailing address

PO BOX 1208
PENDLETON OR
97801-0780
US

V. Phone/Fax

Practice location:
  • Phone: 541-276-6700
  • Fax:
Mailing address:
  • Phone: 541-276-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number38D0628506
License Number StateOR

VIII. Authorized Official

Name: MS. GOLDIE MANDELLA
Title or Position: MANAGER, BILLING OPERATIONS
Credential:
Phone: 541-278-4743