Provider Demographics
NPI:1023154465
Name:DIAGNOSTIC VASCULAR LABORATORY, LLC
Entity type:Organization
Organization Name:DIAGNOSTIC VASCULAR LABORATORY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNGSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-575-7652
Mailing Address - Street 1:3911 CASTLEVALE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-7807
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3911 CASTLEVALE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-7807
Practice Address - Country:US
Practice Address - Phone:509-575-7652
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7017049Medicaid
WAGAB32874Medicare ID - Type Unspecified