Healthcare Provider Details

I. General information

NPI: 1255087201
Provider Name (Legal Business Name): GRAVITAS LABS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11903 E WELLAND ST STE F
INDIANAPOLIS IN
46229-3911
US

IV. Provider business mailing address

1126 INDIAN TRL
CARMEL IN
46032-2804
US

V. Phone/Fax

Practice location:
  • Phone: 800-537-3381
  • Fax:
Mailing address:
  • Phone: 317-701-4191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: MS. TERRY DOVE PITTMAN
Title or Position: CEO
Credential:
Phone: 317-701-4191