Healthcare Provider Details

I. General information

NPI: 1780042937
Provider Name (Legal Business Name): COMMONWEALTH DIAGNOSTICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2016
Last Update Date: 02/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2270 UNIVERSITY AVE STE 1B
BRONX NY
10468-6265
US

IV. Provider business mailing address

1924 OCEAN AVE APT 2B
BROOKLYN NY
11230-6719
US

V. Phone/Fax

Practice location:
  • Phone: 917-562-7003
  • Fax: 617-275-0851
Mailing address:
  • Phone: 917-562-7003
  • Fax: 617-275-0851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: GEORGE TKEBUCHAVA
Title or Position: PRESIDENT
Credential:
Phone: 917-562-7003