Provider Demographics
NPI:1881153393
Name:MGM LABS LLC
Entity type:Organization
Organization Name:MGM LABS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:MCGINLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-674-6292
Mailing Address - Street 1:11350 SW VILLAGE PKWY STE 314
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2352
Mailing Address - Country:US
Mailing Address - Phone:561-674-6292
Mailing Address - Fax:
Practice Address - Street 1:11350 SW VILLAGE PKWY STE 314
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2352
Practice Address - Country:US
Practice Address - Phone:561-674-6292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory