Provider Demographics
NPI:1083375893
Name:TBF DIAGNOSTIC INC
Entity Type:Organization
Organization Name:TBF DIAGNOSTIC INC
Other - Org Name:TBF DIAGNOSTIC INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAKALA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-420-6894
Mailing Address - Street 1:2916 CENTRAL ST # 2A
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1212
Mailing Address - Country:US
Mailing Address - Phone:224-999-7624
Mailing Address - Fax:847-589-5944
Practice Address - Street 1:2916 CENTRAL ST # 2A
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1212
Practice Address - Country:US
Practice Address - Phone:224-999-7624
Practice Address - Fax:847-589-5944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-04
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center