Provider Demographics
NPI:1467723502
Name:UNIVERSAL DERMATOPATHOLOGY LAB, PLLC
Entity Type:Organization
Organization Name:UNIVERSAL DERMATOPATHOLOGY LAB, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WON
Authorized Official - Middle Name:K
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-419-3607
Mailing Address - Street 1:2650 HORIZON DR SE
Mailing Address - Street 2:SUITE 233
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7519
Mailing Address - Country:US
Mailing Address - Phone:616-419-3607
Mailing Address - Fax:616-419-3679
Practice Address - Street 1:2650 HORIZON DR SE
Practice Address - Street 2:SUITE 233
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7519
Practice Address - Country:US
Practice Address - Phone:616-419-3607
Practice Address - Fax:616-419-3679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-20
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI23D2034749291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory