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General NPI Number Information
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NPI Number | 1568839173
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Entity Type | Organization
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Legal Business Name | RIDGEWOOD DIAGNOSTIC LABORATORY, LLC
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Dates
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Enumeration Date | 08/31/2015
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Last Update Date | 11/20/2018
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Provider Practice Location Address
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Address Line | 126 STATE STREET 2ND FLOOR
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City | HACKENSACK
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State | NJ
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Zip | 07601
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Country | US
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Telephone | 973-542-2343
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Fax | 201-632-6548
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Provider Business Mailing Address
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Address Line | 126 STATE STREET 2ND FLOOR
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City | HACKENSACK
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State | NJ
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Zip | 07601
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Country | US
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Telephone | 973-542-2343
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Fax | 201-632-6548
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Authorized Official
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Title or Position | PRESIDENT
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Name | ALEXANDR ZAITSEV
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Credential | M.D.
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Telephone | 862-703-0506
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 31D2109691
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License Number State | NJ
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