=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013466432
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLINICAL CONNECT LABORATORIES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2016
-----------------------------------------------------
Last Update Date | 04/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30675 STEPHENSON HWY STE L1
-----------------------------------------------------
City | MADISON HEIGHTS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48071-1635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-392-6042
-----------------------------------------------------
Fax | 888-392-6043
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30675 STEPHENSON HWY STE L1
-----------------------------------------------------
City | MADISON HEIGHTS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48071-1635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-392-6042
-----------------------------------------------------
Fax | 888-392-6043
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | YISROEL SIGLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 888-392-6042
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------