Provider Demographics
NPI:1184311367
Name:INNOVATIVE DIAGNOSTICS LABORATORY LLC
Entity type:Organization
Organization Name:INNOVATIVE DIAGNOSTICS LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LAB MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MONA
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCCILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-315-0333
Mailing Address - Street 1:7 LINCOLN HWY STE 101A
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-3965
Mailing Address - Country:US
Mailing Address - Phone:908-315-0333
Mailing Address - Fax:908-315-0125
Practice Address - Street 1:7 LINCOLN HWY STE 101A
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-3965
Practice Address - Country:US
Practice Address - Phone:908-315-0333
Practice Address - Fax:908-315-0125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory