=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164651618
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WESTERN SLOPE LABORATORY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2009
-----------------------------------------------------
Last Update Date | 11/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1197 ROCHESTER RD SUITE K
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48083-6031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-307-1168
-----------------------------------------------------
Fax | 248-307-1189
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1197 ROCHESTER RD SUITE K
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48083-6031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-307-1168
-----------------------------------------------------
Fax | 248-307-1189
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | MR. THOMAS L. MCCORMICK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-307-1168
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 23D1047507
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------