Provider Demographics
NPI:1801547104
Name:TJ EXPRESS LAB, LLC
Entity type:Organization
Organization Name:TJ EXPRESS LAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TACIANA
Authorized Official - Middle Name:F
Authorized Official - Last Name:ALCOFORADO
Authorized Official - Suffix:
Authorized Official - Credentials:NCPT
Authorized Official - Phone:978-727-5654
Mailing Address - Street 1:PO BOX 971130
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33097-1130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1103 NE 33RD ST
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064-5226
Practice Address - Country:US
Practice Address - Phone:954-892-4554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service