Provider Demographics
NPI:1710562525
Name:GREENLEAVES DIAGNOSTIC LABORATORIES LLC
Entity Type:Organization
Organization Name:GREENLEAVES DIAGNOSTIC LABORATORIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KANDHOROV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-220-2903
Mailing Address - Street 1:PO BOX 1692
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10150-1692
Mailing Address - Country:US
Mailing Address - Phone:716-245-7886
Mailing Address - Fax:
Practice Address - Street 1:202 N TEXAS AVE STE 150
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4967
Practice Address - Country:US
Practice Address - Phone:716-245-7886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory