=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114634482
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFELINE MEDICAL TESTING PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2022
-----------------------------------------------------
Last Update Date | 11/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1041 3RD AVE # 203
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10065-8114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-583-2969
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 40 ORMOND ST
-----------------------------------------------------
City | DIX HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11746-6333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR/CEO
-----------------------------------------------------
Name | DR. DIEGO DIAZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 917-678-8400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------