Healthcare Provider Details

I. General information

NPI: 1073686846
Provider Name (Legal Business Name): MEQUON LABS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 DONGES BAY ROAD
MEQUON WI
53092-5528
US

IV. Provider business mailing address

1415 DONGES BAY ROAD
MEQUON WI
53092-5528
US

V. Phone/Fax

Practice location:
  • Phone: 262-240-5443
  • Fax: 262-240-0755
Mailing address:
  • Phone: 262-240-5443
  • Fax: 262-240-0755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MOZAFAR SALEKI
Title or Position: LABORATORY DIRECTOR
Credential: MS MT
Phone: 262-240-5443