MEDICARE: PSO LABORATORY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory	23D2036829	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	23D2036829	OTHER	MI	CLIA

General Provider Information

NPI Number	:	1306198478
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSO LABORATORY LLC

Provider Business Mailing Address
First Line	:	PO BOX 10
Second Line	:
City	:	MASON
State	:	MI
Zip	:	48854-0010
Country	:	US
Telephone Number	:	517-676-9788
Fax Number	:	517-676-3438

Provider Business Practice Location Address
First Line	:	2025 S WASHINGTON AVE
Second Line	:	SUITE 202
City	:	LANSING
State	:	MI
Zip	:	48910-0828
Country	:	US
Telephone Number	:	517-575-6487
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PAULA REEVES
Credential	:
Telephone Number	:	517-575-6487

Provider Enumeration Date	:	10/12/2012
Last Update Date	:	10/12/2012

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Directions to “PSO LABORATORY LLC ” Practice Location

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