MEDICARE: PREVENT DIAGNOSTIC CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1396053450
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREVENT DIAGNOSTIC CORP

Provider Business Mailing Address
First Line	:	205 WOOD RD
Second Line	:
City	:	LAKE GROVE
State	:	NY
Zip	:	11755-1856
Country	:	US
Telephone Number	:	631-676-4336
Fax Number	:	631-676-4337

Provider Business Practice Location Address
First Line	:	205 WOOD RD
Second Line	:
City	:	LAKE GROVE
State	:	NY
Zip	:	11755-1856
Country	:	US
Telephone Number	:	631-676-4336
Fax Number	:	631-676-4337

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GAMZE YANIK
Credential	:
Telephone Number	:	631-676-4336

Provider Enumeration Date	:	09/22/2010
Last Update Date	:	09/22/2010

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