=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154557213
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRESTVIEW CLINICAL LABORATORY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2009
-----------------------------------------------------
Last Update Date | 06/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1471 S RIVERSIDE AVE
-----------------------------------------------------
City | RIALTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92376-7703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-877-1361
-----------------------------------------------------
Fax | 909-877-0854
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1471 S RIVERSIDE AVE
-----------------------------------------------------
City | RIALTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92376-7703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-877-1361
-----------------------------------------------------
Fax | 909-877-0854
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. LEONA JUNE BERGLUND
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-877-1361
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | CLF 11381
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------