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NPI Code Detail

MEDICARE: CASCADE MEDICAL TESTING LAB, INC.

MEDICARE: CASCADE MEDICAL TESTING LAB, INC.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1291U00000XClinical Medical Laboratory

General Provider Information

NPI Number : 1760557375
Entity Type Code : Organization
Provider Name (Legal Business Name) : CASCADE MEDICAL TESTING LAB, INC.
Provider Business Mailing Address
First Line : PO BOX 88247
Second Line :
City : KENTWOOD
State : MI
Zip : 49518-0247
Country : US
Telephone Number : 616-734-0335
Fax Number : 616-949-8540
Provider Business Practice Location Address
First Line : 2251 E PARIS AVE SE
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49546-2431
Country : US
Telephone Number : 616-956-6090
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : MR. ROBERT DEJONGE
Credential : MD
Telephone Number : 616-956-6090
Provider Enumeration Date : 11/21/2006
Last Update Date : 10/19/2007

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