Provider Demographics
NPI:1942873484
Name:PROPHASE DIAGNOSTICS NY, INC
Entity Type:Organization
Organization Name:PROPHASE DIAGNOSTICS NY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PROPHASE
Authorized Official - Middle Name:
Authorized Official - Last Name:LABS, INC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-464-6121
Mailing Address - Street 1:711 STEWART AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4734
Mailing Address - Country:US
Mailing Address - Phone:516-464-6121
Mailing Address - Fax:
Practice Address - Street 1:711 STEWART AVE
Practice Address - Street 2:STE 200
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4719
Practice Address - Country:US
Practice Address - Phone:516-464-6121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-22
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory