Healthcare Provider Details

I. General information

NPI: 1053132274
Provider Name (Legal Business Name): MEDTECH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29777 TELEGRAPH RD
SOUTHFIELD MI
48034-1303
US

IV. Provider business mailing address

29777 TELEGRAPH RD
SOUTHFIELD MI
48034-1303
US

V. Phone/Fax

Practice location:
  • Phone: 313-425-1520
  • Fax:
Mailing address:
  • Phone:
  • 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 Code305S00000X
TaxonomyPoint of Service
License Number
License Number State

VIII. Authorized Official

Name: JAZLYN DAVIS
Title or Position: OWNER
Credential: LABORATORY DIRECTOR
Phone: 313-425-1520