Provider Demographics
NPI:1134670904
Name:PONTIAC LABS, LLC
Entity type:Organization
Organization Name:PONTIAC LABS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:MICHEAL
Authorized Official - Last Name:DAMRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-640-9664
Mailing Address - Street 1:461 W HURON ST
Mailing Address - Street 2:SECOND FLOOR LAB
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-1601
Mailing Address - Country:US
Mailing Address - Phone:248-857-7200
Mailing Address - Fax:248-857-6905
Practice Address - Street 1:461 W HURON ST
Practice Address - Street 2:SECOND FLOOR LAB
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-1601
Practice Address - Country:US
Practice Address - Phone:248-857-7200
Practice Address - Fax:248-857-6905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI23D0685754291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory