Provider Demographics
NPI:1316690290
Name:MACOMB FAMILY LAB SERVICES LLC
Entity type:Organization
Organization Name:MACOMB FAMILY LAB SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONI
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:313-727-5009
Mailing Address - Street 1:26140 CROCKER BLVD STE 1013
Mailing Address - Street 2:
Mailing Address - City:HARRISON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48045-2454
Mailing Address - Country:US
Mailing Address - Phone:313-727-5009
Mailing Address - Fax:
Practice Address - Street 1:31110 SARATOGA AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-1619
Practice Address - Country:US
Practice Address - Phone:313-727-5009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No251J00000XAgenciesNursing Care