Provider Demographics
NPI:1679337802
Name:WATERFORD DX LLC
Entity type:Organization
Organization Name:WATERFORD DX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:AFFINITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-503-9177
Mailing Address - Street 1:6830 N 55TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-3304
Mailing Address - Country:US
Mailing Address - Phone:602-774-2097
Mailing Address - Fax:
Practice Address - Street 1:6830 N 55TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-3304
Practice Address - Country:US
Practice Address - Phone:602-774-2097
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-08
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory