Healthcare Provider Details

I. General information

NPI: 1912513185
Provider Name (Legal Business Name): MVP DIAGNOSTIC LABORATORY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 02/23/2021
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28300 FRANKLIN RD STE 100
SOUTHFIELD MI
48034-1657
US

IV. Provider business mailing address

3785 BAY RD
SAGINAW MI
48603-2433
US

V. Phone/Fax

Practice location:
  • Phone: 248-353-6200
  • Fax:
Mailing address:
  • Phone: 989-791-2455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: DUSTIN HAYES
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 248-353-6200