Provider Demographics
NPI:1669451563
Name:SOPHORA DIAGNOSTIC LAB INC
Entity Type:Organization
Organization Name:SOPHORA DIAGNOSTIC LAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKHAIL
Authorized Official - Middle Name:I
Authorized Official - Last Name:KANTIUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-969-2884
Mailing Address - Street 1:PO BOX 740048
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:79-18 164 ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432
Practice Address - Country:US
Practice Address - Phone:718-969-2884
Practice Address - Fax:718-969-2576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-10
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00236Medicare PIN