Healthcare Provider Details

I. General information

NPI: 1184928434
Provider Name (Legal Business Name): GOLD COAST DIAGNOSTIC SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2010
Last Update Date: 12/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 N MICHIGAN AVE SUITE 985W
CHICAGO IL
60611-2252
US

IV. Provider business mailing address

845 N MICHIGAN AVE SUITE 985W
CHICAGO IL
60611-2252
US

V. Phone/Fax

Practice location:
  • Phone: 312-521-5500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State

VIII. Authorized Official

Name: ROBERTO DIAZ
Title or Position: PRESIDENT/ CEO
Credential:
Phone: 312-521-5500