=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780042937
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMONWEALTH DIAGNOSTICS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2016
-----------------------------------------------------
Last Update Date | 02/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2270 UNIVERSITY AVE STE 1B
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10468-6265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-562-7003
-----------------------------------------------------
Fax | 617-275-0851
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1924 OCEAN AVE APT 2B
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11230-6719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-562-7003
-----------------------------------------------------
Fax | 617-275-0851
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | GEORGE TKEBUCHAVA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 917-562-7003
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------