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General NPI Number Information
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NPI Number | 1255087201
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Entity Type | Organization
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Legal Business Name | GRAVITAS LABS LLC
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Dates
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Enumeration Date | 03/01/2022
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Last Update Date | 03/01/2022
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Provider Practice Location Address
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Address Line | 11903 E WELLAND ST STE F
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City | INDIANAPOLIS
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State | IN
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Zip | 46229-3911
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Country | US
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Telephone | 800-537-3381
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Fax |
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Provider Business Mailing Address
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Address Line | 1126 INDIAN TRL
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City | CARMEL
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State | IN
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Zip | 46032-2804
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Country | US
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Telephone | 317-701-4191
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MS. TERRY DOVE PITTMAN
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Credential |
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Telephone | 317-701-4191
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number |
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License Number State |
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Taxonomy #2
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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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