Provider Demographics
NPI:1821453903
Name:ADVANCED CENTRAL LABORATORY, LLC
Entity Type:Organization
Organization Name:ADVANCED CENTRAL LABORATORY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:ITANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-656-1199
Mailing Address - Street 1:14717 CHAMPAIGN RD
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-1693
Mailing Address - Country:US
Mailing Address - Phone:313-656-1199
Mailing Address - Fax:
Practice Address - Street 1:14717 CHAMPAIGN RD
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-1693
Practice Address - Country:US
Practice Address - Phone:313-656-1199
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-16
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory