Healthcare Provider Details

I. General information

NPI: 1467723502
Provider Name (Legal Business Name): UNIVERSAL DERMATOPATHOLOGY LAB, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2012
Last Update Date: 01/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 HORIZON DR SE SUITE 233
GRAND RAPIDS MI
49546-7519
US

IV. Provider business mailing address

2650 HORIZON DR SE SUITE 233
GRAND RAPIDS MI
49546-7519
US

V. Phone/Fax

Practice location:
  • Phone: 616-419-3607
  • Fax: 616-419-3679
Mailing address:
  • Phone: 616-419-3607
  • Fax: 616-419-3679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number23D2034749
License Number StateMI

VIII. Authorized Official

Name: DR. WON K LEE
Title or Position: DIRECTOR
Credential: M.D.
Phone: 616-419-3607