Provider Demographics
NPI:1730292822
Name:MOLECULAR DIAGNOSTIC LABORATORY LLC
Entity Type:Organization
Organization Name:MOLECULAR DIAGNOSTIC LABORATORY LLC
Other - Org Name:SINAI LABS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:SVITLIK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:203-729-6230
Mailing Address - Street 1:131 QUINN ST
Mailing Address - Street 2:
Mailing Address - City:NAUGATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06770
Mailing Address - Country:US
Mailing Address - Phone:203-729-6230
Mailing Address - Fax:203-729-2025
Practice Address - Street 1:131 QUINN ST
Practice Address - Street 2:
Practice Address - City:NAUGATUCK
Practice Address - State:CT
Practice Address - Zip Code:06770
Practice Address - Country:US
Practice Address - Phone:203-729-6230
Practice Address - Fax:203-729-2025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCL0632291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004221016Medicaid