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General NPI Number Information
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NPI Number | 1679337802
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Entity Type | Organization
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Legal Business Name | WATERFORD DX LLC
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Dates
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Enumeration Date | 02/08/2024
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Last Update Date | 12/26/2024
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Provider Practice Location Address
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Address Line | 6830 N 55TH AVE STE 100
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City | GLENDALE
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State | AZ
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Zip | 85301-3304
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Country | US
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Telephone | 602-774-2097
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Fax |
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Provider Business Mailing Address
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Address Line | 6830 N 55TH AVE STE 100
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City | GLENDALE
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State | AZ
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Zip | 85301-3304
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Country | US
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Telephone | 602-774-2097
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. FRANK AFFINITO
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Credential |
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Telephone | 310-503-9177
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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 |
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License Number State |
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