Basic Information
| Provider Information | |||||||||
| NPI: | 1437245784 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI- COUNTY DIAGNOSTIC TESTING SERVICES LLC | ||||||||
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| OtherOrganizationName: | SAINT VINCENT DIAGNOSTIC TESTING IN BRADFORD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3530 PEACH ST | ||||||||
| Address2: | SUITE LL1 | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165082768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148605000 | ||||||||
| FaxNumber: | 8148605050 | ||||||||
| Practice Location | |||||||||
| Address1: | 52 DAVIS ST | ||||||||
| Address2: | |||||||||
| City: | BRADFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 167012016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143683150 | ||||||||
| FaxNumber: | 8143684968 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 10/11/2007 | ||||||||
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| AuthorizedOfficialLastName: | KRESSE | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | BOARD SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 8144527888 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CLINICAL SERVICES INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 1012141200001 | 05 | PA | MEDICAID |