Provider Demographics
NPI:1083770366
Name:IMMUNE & DIAGNOSTIC LABORATORY INC.
Entity Type:Organization
Organization Name:IMMUNE & DIAGNOSTIC LABORATORY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:B
Authorized Official - Last Name:SALKINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-848-9000
Mailing Address - Street 1:31700 W 12 MILE RD
Mailing Address - Street 2:STE 220
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-4424
Mailing Address - Country:US
Mailing Address - Phone:248-848-9000
Mailing Address - Fax:248-489-0058
Practice Address - Street 1:31700 W 12 MILE RD
Practice Address - Street 2:STE 220
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-4424
Practice Address - Country:US
Practice Address - Phone:248-848-9000
Practice Address - Fax:248-489-0058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
0M03780Medicare ID - Type Unspecified