Healthcare Provider Details

I. General information

NPI: 1740397124
Provider Name (Legal Business Name): KENT PATHOLOGY LABORATORY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 06/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 HORIZON DR SE SUITE B
GRAND RAPIDS MI
49546-7519
US

IV. Provider business mailing address

2650 HORIZON DR SE SUITE B
GRAND RAPIDS MI
49546-7519
US

V. Phone/Fax

Practice location:
  • Phone: 616-458-1255
  • Fax: 616-458-1292
Mailing address:
  • Phone: 616-458-1255
  • Fax: 616-458-1292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. WON KYU LEE
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 616-774-0209