Provider Demographics
NPI:1255087201
Name:GRAVITAS LABS LLC
Entity type:Organization
Organization Name:GRAVITAS LABS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:DOVE PITTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-701-4191
Mailing Address - Street 1:1126 INDIAN TRL
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-2804
Mailing Address - Country:US
Mailing Address - Phone:317-701-4191
Mailing Address - Fax:
Practice Address - Street 1:11903 E WELLAND ST STE F
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-3911
Practice Address - Country:US
Practice Address - Phone:800-537-3381
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-01
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No302F00000XManaged Care OrganizationsExclusive Provider Organization