Provider Demographics
NPI:1972538593
Name:WANTAGH DIAGNOSTIC LAB INC
Entity Type:Organization
Organization Name:WANTAGH DIAGNOSTIC LAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DONOHUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-221-0002
Mailing Address - Street 1:1228 WANTAGH AVENUE
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793
Mailing Address - Country:US
Mailing Address - Phone:516-221-0002
Mailing Address - Fax:516-221-3241
Practice Address - Street 1:1228 WANTAGH AVENUE
Practice Address - Street 2:SUITE LLI
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793
Practice Address - Country:US
Practice Address - Phone:516-221-0002
Practice Address - Fax:516-221-3241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
L81321Medicare UPIN
L81321Medicare ID - Type Unspecified