Provider Demographics
NPI:1104996248
Name:UNIVERSAL DIAGNOSTIC LABORATORY, INC.
Entity type:Organization
Organization Name:UNIVERSAL DIAGNOSTIC LABORATORY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAMO
Authorized Official - Middle Name:
Authorized Official - Last Name:BALIGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-781-6560
Mailing Address - Street 1:12056 MOUNT VERNON AVE
Mailing Address - Street 2:SUITE 358
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5116
Mailing Address - Country:US
Mailing Address - Phone:866-455-5700
Mailing Address - Fax:909-824-3243
Practice Address - Street 1:1414 NEWKIRK AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-6522
Practice Address - Country:US
Practice Address - Phone:718-859-4777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory