Basic Information
| Provider Information | |||||||||
| NPI: | 1306198478 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PSO LABORATORY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10 | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488540010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176769788 | ||||||||
| FaxNumber: | 5176763438 | ||||||||
| Practice Location | |||||||||
| Address1: | 2025 S WASHINGTON AVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489100828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5175756487 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2012 | ||||||||
| LastUpdateDate: | 10/12/2012 | ||||||||
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| AuthorizedOfficialLastName: | REEVES | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5175756487 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 23D2036829 | MI | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 23D2036829 | 01 | MI | CLIA | OTHER |