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General NPI Number Information
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NPI Number | 1710562525
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Entity Type | Organization
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Legal Business Name | GREENLEAVES DIAGNOSTIC LABORATORIES LLC
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Dates
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Enumeration Date | 03/12/2021
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Last Update Date | 03/12/2021
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Provider Practice Location Address
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Address Line | 202 N TEXAS AVE STE 150
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City | WEBSTER
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State | TX
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Zip | 77598-4967
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Country | US
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Telephone | 716-245-7886
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1692
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City | NEW YORK
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State | NY
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Zip | 10150-1692
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Country | US
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Telephone | 716-245-7886
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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. DANIEL KANDHOROV
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Credential |
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Telephone | 631-220-2903
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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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