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General NPI Number Information
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NPI Number | 1780640490
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Entity Type | Organization
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Legal Business Name | JOLI DIAGNOSTIC INC
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Dates
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Enumeration Date | 04/21/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2451 WEHRLE DR
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City | WILLIAMSVILLE
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State | NY
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Zip | 14221-7141
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Country | US
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Telephone | 716-639-0443
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Fax | 716-639-0471
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Provider Business Mailing Address
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Address Line | 2451 WEHRLE DR
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City | WILLIAMSVILLE
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State | NY
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Zip | 14221-7141
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Country | US
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Telephone | 716-639-0443
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Fax | 716-639-0471
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Authorized Official
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Title or Position | LABORATORY DIRECTOR
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Name | MR. AMIN TJOTA
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Credential | MD PHD
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Telephone | 716-639-0443
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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 | 49181421A170
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License Number State | NY
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