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General NPI Number Information
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NPI Number | 1164815924
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Entity Type | Organization
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Legal Business Name | MNA LAB, LLC
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Dates
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Enumeration Date | 03/17/2015
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Last Update Date | 03/17/2015
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Provider Practice Location Address
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Address Line | 24555 SOUTHFIELD RD SUITE 190
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City | SOUTHFIELD
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State | MI
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Zip | 48075-2738
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Country | US
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Telephone | 248-234-8739
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Fax |
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Provider Business Mailing Address
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Address Line | 34025 HARPER AVE
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City | CLINTON TWP
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State | MI
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Zip | 48035-3737
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Country | US
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Telephone | 586-445-9900
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. THOMAS GIANCARLO
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Credential | D.O.
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Telephone | 586-445-9900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State |
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