Provider Demographics
NPI:1780042937
Name:COMMONWEALTH DIAGNOSTICS INC
Entity type:Organization
Organization Name:COMMONWEALTH DIAGNOSTICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:TKEBUCHAVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-562-7003
Mailing Address - Street 1:1924 OCEAN AVE
Mailing Address - Street 2:APT 2B
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-6719
Mailing Address - Country:US
Mailing Address - Phone:917-562-7003
Mailing Address - Fax:617-275-0851
Practice Address - Street 1:2270 UNIVERSITY AVE
Practice Address - Street 2:STE 1B
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-6265
Practice Address - Country:US
Practice Address - Phone:917-562-7003
Practice Address - Fax:617-275-0851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-03
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty