Provider Demographics
NPI:1376620633
Name:HISTODIAGNOSTIC LABORATORIES
Entity Type:Organization
Organization Name:HISTODIAGNOSTIC LABORATORIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-345-1387
Mailing Address - Street 1:150 N BURGESS ST
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-1106
Mailing Address - Country:US
Mailing Address - Phone:989-345-1387
Mailing Address - Fax:989-345-2591
Practice Address - Street 1:150 N BURGESS ST
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-1106
Practice Address - Country:US
Practice Address - Phone:989-345-1387
Practice Address - Fax:989-345-2591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301030046291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory