1508169145 NPI number — PHYSICIANS TOXICOLOGY LABORATORY, LLC

Table of content: (NPI 1508169145)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508169145 NPI number — PHYSICIANS TOXICOLOGY LABORATORY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIANS TOXICOLOGY LABORATORY, 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:
6
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:
1508169145
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
801 LAUREL OAK DR
Provider Second Line Business Mailing Address:
STE. 102
Provider Business Mailing Address City Name:
NAPLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34108-2748
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-213-1600
Provider Business Mailing Address Fax Number:
239-213-1940

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4433 MANCHESTER RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KALAMAZOO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-213-1600
Provider Business Practice Location Address Fax Number:
239-213-1940
Provider Enumeration Date:
12/20/2010

Additional Information

Authorized Official

Authorized Official Last Name:
LUND
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
RYAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
239-269-0035

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , 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)





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