Provider Demographics
NPI:1114245974
Name:PROST DATA INC
Entity Type:Organization
Organization Name:PROST DATA INC
Other - Org Name:OUR LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OPPENHEIMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-628-4378
Mailing Address - Street 1:PO BOX 291209
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37229-1209
Mailing Address - Country:US
Mailing Address - Phone:615-874-0410
Mailing Address - Fax:615-345-4659
Practice Address - Street 1:343 GOLD ST
Practice Address - Street 2:1412
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-3055
Practice Address - Country:US
Practice Address - Phone:347-628-4378
Practice Address - Fax:347-521-1275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-04
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8504291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
33D2004917OtherCLIA