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General NPI Number Information
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NPI Number | 1962774968
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Entity Type | Organization
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Legal Business Name | TRIDENT DIAGNOSTICS, LLC
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Dates
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Enumeration Date | 02/06/2012
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Last Update Date | 02/06/2012
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Provider Practice Location Address
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Address Line | 16801 ADDISON RD STE 124
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City | ADDISON
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State | TX
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Zip | 75001-5696
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Country | US
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Telephone | 972-380-5630
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Fax | 972-380-5635
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Provider Business Mailing Address
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Address Line | 10071 BRONX AVE
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City | SKOKIE
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State | IL
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Zip | 60077-1003
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Country | US
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Telephone | 847-322-2438
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Fax | 312-256-9749
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Authorized Official
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Title or Position | MANAGER
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Name | MR. GEORGE CHERNY
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Credential |
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Telephone | 847-322-2438
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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 | TX
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