Provider Demographics
NPI:1033726633
Name:SHORES DIAGNOSTIC LLC
Entity Type:Organization
Organization Name:SHORES DIAGNOSTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NORMA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:BARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-730-7579
Mailing Address - Street 1:3611 CARPENTER ST STE 6
Mailing Address - Street 2:
Mailing Address - City:HAMTRAMCK
Mailing Address - State:MI
Mailing Address - Zip Code:48212-2784
Mailing Address - Country:US
Mailing Address - Phone:313-285-8728
Mailing Address - Fax:313-784-9055
Practice Address - Street 1:3611 CARPENTER ST STE 6
Practice Address - Street 2:
Practice Address - City:HAMTRAMCK
Practice Address - State:MI
Practice Address - Zip Code:48212-2784
Practice Address - Country:US
Practice Address - Phone:313-285-8728
Practice Address - Fax:313-784-9055
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHORES DIAGNOSTIC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1235110289Medicaid