=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205203379
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROGRESSIVE DIAGNOSTICS ONE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2015
-----------------------------------------------------
Last Update Date | 11/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35 NUTMEG DR SUITE 305
-----------------------------------------------------
City | TRUMBULL
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06611-5431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-503-8803
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35 NUTMEG DR SUITE 305
-----------------------------------------------------
City | TRUMBULL
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06611-5431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-503-8803
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | CURT KULIGA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 888-503-8803
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 07D2090968
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------