Provider Demographics
NPI:1639249410
Name:HOLLYWOOD DIAGNOSTIC CENTER INC
Entity Type:Organization
Organization Name:HOLLYWOOD DIAGNOSTIC CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:AYALA
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-358-2539
Mailing Address - Street 1:1907 AMERICAN DR # L1
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-1236
Mailing Address - Country:US
Mailing Address - Phone:608-358-2539
Mailing Address - Fax:
Practice Address - Street 1:224 W EXCHANGE ST STE 360
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44302-1715
Practice Address - Country:US
Practice Address - Phone:608-358-2539
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI291U00000X
OH291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory