=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649555814
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTPATH DIAGNOSTICS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2011
-----------------------------------------------------
Last Update Date | 02/07/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4534 BELL BLVD 2ND FLOOR
-----------------------------------------------------
City | BAYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11361-3353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-279-1271
-----------------------------------------------------
Fax | 718-279-1092
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4534 BELL BLVD 2ND FLOOR
-----------------------------------------------------
City | BAYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11361-3353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-279-1271
-----------------------------------------------------
Fax | 718-279-1092
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ZUJIN LI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 718-279-1271
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 8592
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------