Healthcare Provider Details

I. General information

NPI: 1306198478
Provider Name (Legal Business Name): PSO LABORATORY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2012
Last Update Date: 10/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 S WASHINGTON AVE SUITE 202
LANSING MI
48910-0828
US

IV. Provider business mailing address

PO BOX 10
MASON MI
48854-0010
US

V. Phone/Fax

Practice location:
  • Phone: 517-575-6487
  • Fax:
Mailing address:
  • Phone: 517-676-9788
  • Fax: 517-676-3438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number23D2036829
License Number StateMI

VIII. Authorized Official

Name: PAULA REEVES
Title or Position: OWNER
Credential:
Phone: 517-575-6487