1134670904 NPI number — PONTIAC LABS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134670904 NPI number — PONTIAC LABS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PONTIAC LABS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134670904
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
461 W HURON ST
Provider Second Line Business Mailing Address:
SECOND FLOOR LAB
Provider Business Mailing Address City Name:
PONTIAC
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48341-1601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-857-7200
Provider Business Mailing Address Fax Number:
248-857-6905

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
461 W HURON ST
Provider Second Line Business Practice Location Address:
SECOND FLOOR LAB
Provider Business Practice Location Address City Name:
PONTIAC
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48341-1601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-857-7200
Provider Business Practice Location Address Fax Number:
248-857-6905
Provider Enumeration Date:
10/17/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DAMRON
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
MICHEAL
Authorized Official Title or Position:
GENERAL COUNSEL
Authorized Official Telephone Number:
678-640-9664

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  23D0685754 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)