Provider Demographics
NPI:1073006144
Name:WAKE DIAGNOSTICS INC
Entity Type:Organization
Organization Name:WAKE DIAGNOSTICS INC
Other - Org Name:WAKE DIAGNOSTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GOVERDHAN
Authorized Official - Middle Name:REDDY
Authorized Official - Last Name:VAVILALA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:919-462-1494
Mailing Address - Street 1:5129 NC 55
Mailing Address - Street 2:STE 103
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713
Mailing Address - Country:US
Mailing Address - Phone:919-399-1215
Mailing Address - Fax:919-981-9180
Practice Address - Street 1:5129 NC 55
Practice Address - Street 2:STE 103
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713
Practice Address - Country:US
Practice Address - Phone:919-399-1215
Practice Address - Fax:919-981-9180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-12
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34D2150941291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory