Provider Demographics
NPI:1780640490
Name:JOLI DIAGNOSTIC INC
Entity Type:Organization
Organization Name:JOLI DIAGNOSTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:AMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TJOTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD PHD
Authorized Official - Phone:716-639-0443
Mailing Address - Street 1:2451 WEHRLE DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-7141
Mailing Address - Country:US
Mailing Address - Phone:716-639-0443
Mailing Address - Fax:716-639-0471
Practice Address - Street 1:2451 WEHRLE DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-7141
Practice Address - Country:US
Practice Address - Phone:716-639-0443
Practice Address - Fax:716-639-0471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY49181421A170291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY49181421A170OtherNYS DEPT OF HEALTH