Provider Demographics
NPI:1598599482
Name:DYNACARE DIAGNOSTIC
Entity type:Organization
Organization Name:DYNACARE DIAGNOSTIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NAVDEEP
Authorized Official - Middle Name:
Authorized Official - Last Name:GILL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-862-8636
Mailing Address - Street 1:1151 PRESCOTT AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93619-7541
Mailing Address - Country:US
Mailing Address - Phone:559-862-8636
Mailing Address - Fax:
Practice Address - Street 1:2166 SHAW AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-8901
Practice Address - Country:US
Practice Address - Phone:559-862-9863
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-31
Last Update Date:2024-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory