Basic Information
| Provider Information | |||||||||
| NPI: | 1134670904 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PONTIAC LABS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 461 W HURON ST | ||||||||
| Address2: | SECOND FLOOR LAB | ||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483411601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488577200 | ||||||||
| FaxNumber: | 2488576905 | ||||||||
| Practice Location | |||||||||
| Address1: | 461 W HURON ST | ||||||||
| Address2: | SECOND FLOOR LAB | ||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483411601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488577200 | ||||||||
| FaxNumber: | 2488576905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2016 | ||||||||
| LastUpdateDate: | 10/17/2016 | ||||||||
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| AuthorizedOfficialLastName: | DAMRON | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | MICHEAL | ||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 6786409664 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 23D0685754 | MI | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.