Provider Demographics
NPI:1154930279
Name:DIAGNOSTIC AFFILIATES OF NORTHEAST HOU LLC
Entity type:Organization
Organization Name:DIAGNOSTIC AFFILIATES OF NORTHEAST HOU LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TARASENKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-319-8378
Mailing Address - Street 1:22751 PROFESSIONAL DR STE 210
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-6021
Mailing Address - Country:US
Mailing Address - Phone:281-908-0686
Mailing Address - Fax:
Practice Address - Street 1:22001 NORTHPARK DR STE 221
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-3804
Practice Address - Country:US
Practice Address - Phone:281-319-8378
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-24
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory