Provider Demographics
NPI:1508169145
Name:PHYSICIANS TOXICOLOGY LABORATORY, LLC
Entity Type:Organization
Organization Name:PHYSICIANS TOXICOLOGY LABORATORY, LLC
Other - Org Name:AFFIRMATOX, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:LUND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-269-0035
Mailing Address - Street 1:801 LAUREL OAK DR
Mailing Address - Street 2:STE. 102
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-2748
Mailing Address - Country:US
Mailing Address - Phone:239-213-1600
Mailing Address - Fax:239-213-1940
Practice Address - Street 1:4433 MANCHESTER RD.
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001
Practice Address - Country:US
Practice Address - Phone:239-213-1600
Practice Address - Fax:239-213-1940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-20
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory