=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669786091
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANY PHYSICIANS REFERENCE LABORATORY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2010
-----------------------------------------------------
Last Update Date | 01/07/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24361 GREENFIELD RD STE #209-A
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48075-3139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-421-6415
-----------------------------------------------------
Fax | 734-421-9087
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29771 GREENLAND ST
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48154-3225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-421-6415
-----------------------------------------------------
Fax | 734-421-9087
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. MAZHAR KHAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 734-421-6415
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 23D2009844
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------