Provider Demographics
NPI:1245599901
Name:CLINICAL LABORATORY OF MD, LLC
Entity Type:Organization
Organization Name:CLINICAL LABORATORY OF MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:AJIRI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-799-0086
Mailing Address - Street 1:3319 N ELSTON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-5811
Mailing Address - Country:US
Mailing Address - Phone:773-751-7200
Mailing Address - Fax:
Practice Address - Street 1:24445 NORTHWESTERN HWY
Practice Address - Street 2:SUITE 208
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-6501
Practice Address - Country:US
Practice Address - Phone:248-799-0086
Practice Address - Fax:248-750-0714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-15
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI23D2007657291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory