Provider Demographics
NPI:1740397124
Name:KENT PATHOLOGY LABORATORY PLLC
Entity Type:Organization
Organization Name:KENT PATHOLOGY LABORATORY PLLC
Other - Org Name:KENT PATHOLOGY LABORATORY LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WON
Authorized Official - Middle Name:KYU
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-774-0209
Mailing Address - Street 1:2650 HORIZON DR SE
Mailing Address - Street 2:SUITE B
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7519
Mailing Address - Country:US
Mailing Address - Phone:616-458-1255
Mailing Address - Fax:616-458-1292
Practice Address - Street 1:2650 HORIZON DR SE
Practice Address - Street 2:SUITE B
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7519
Practice Address - Country:US
Practice Address - Phone:616-458-1255
Practice Address - Fax:616-458-1292
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENT PATHOLOGY LABORATORY PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-23
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Single Specialty