=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053132274
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDTECH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2024
-----------------------------------------------------
Last Update Date | 11/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29777 TELEGRAPH RD
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48034-1303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-425-1520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29777 TELEGRAPH RD
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48034-1303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JAZLYN DAVIS
-----------------------------------------------------
Credential | LABORATORY DIRECTOR
-----------------------------------------------------
Telephone | 313-425-1520
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------