Provider Demographics
NPI:1043615214
Name:ADVANCE TOXICOLOGY LABORATORIES, LLC
Entity Type:Organization
Organization Name:ADVANCE TOXICOLOGY LABORATORIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:OSMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-885-9775
Mailing Address - Street 1:4950 PEGGY ST
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-4420
Mailing Address - Country:US
Mailing Address - Phone:248-885-9775
Mailing Address - Fax:
Practice Address - Street 1:24555 SOUTHFIELD RD STE L90
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2738
Practice Address - Country:US
Practice Address - Phone:248-885-9775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-29
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory