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General NPI Number Information
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NPI Number | 1528376688
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Entity Type | Organization
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Legal Business Name | MEDVISTA LABORATORY INC
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Dates
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Enumeration Date | 09/22/2010
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Last Update Date | 09/22/2010
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Provider Practice Location Address
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Address Line | 3138 W CERMAK RD SUITE 103
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City | CHICAGO
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State | IL
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Zip | 60623-3306
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Country | US
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Telephone | 773-762-4331
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Fax | 773-762-4333
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Provider Business Mailing Address
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Address Line | 3029 E 92ND ST SUITE 1
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City | CHICAGO
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State | IL
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Zip | 60617-4500
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Country | US
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Telephone | 773-218-1004
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Fax | 773-762-4333
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Authorized Official
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Title or Position | PRESIDENT
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Name | JOHN MWESIGWA
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Credential | NURSE
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Telephone | 773-218-1004
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 14D2011212
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License Number State | IL
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