Organization
HARVARD LAB & X-RAY, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARLIN LARSEN PHD, BLD (OWNER)
(541) 672-9349
Entity
Organization
Contact information
Practice address
1813 W HARVARD AVE, SUITE 102, ROSEBURG, OR 97470-2752
(541) 440-6316
(541) 464-4336
Mailing address
1813 W HARVARD AVE, SUITE 102, ROSEBURG, OR 97470-2752
(541) 440-6316
(541) 464-4336
Taxonomy
Speciality
Code
Description
License number
State
2085B0100X
Body Imaging Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0000003290
BLUE CROSS OF OREGON
OR
01
—
166173
DOUGLAS COUNTY IPA
OR
05
—
288032
—
OR
01
—
J0625
PACIFIC SOURCE
OR
Enumeration date
11/14/2006
Last updated
08/22/2020
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