Provider Demographics
NPI:1609163088
Name:CAPITAL UROLOGICAL ASSOCIATES LABORATORY
Entity Type:Organization
Organization Name:CAPITAL UROLOGICAL ASSOCIATES LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:STOCKALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-349-3900
Mailing Address - Street 1:PO BOX 1070
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48805-1070
Mailing Address - Country:US
Mailing Address - Phone:517-349-3900
Mailing Address - Fax:517-349-3939
Practice Address - Street 1:2090 JOLLY RD STE 150
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-6036
Practice Address - Country:US
Practice Address - Phone:517-349-3900
Practice Address - Fax:517-349-3939
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ERIC STOCKALL MD PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301046439291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23D0992826OtherCLIA