1134405012 NPI number — EPINEX DIAGNOSTICS LABORATORIES, INC.

Table of content: (NPI 1134405012)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134405012 NPI number — EPINEX DIAGNOSTICS LABORATORIES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EPINEX DIAGNOSTICS LABORATORIES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134405012
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14351 MYFORD RD
Provider Second Line Business Mailing Address:
SUITE K
Provider Business Mailing Address City Name:
TUSTIN
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92780-7074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-464-5682
Provider Business Mailing Address Fax Number:
714-731-7229

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14351 MYFORD RD
Provider Second Line Business Practice Location Address:
SUITE K
Provider Business Practice Location Address City Name:
TUSTIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92780-7074
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-464-5682
Provider Business Practice Location Address Fax Number:
714-731-1229
Provider Enumeration Date:
10/24/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MADIREDDY
Authorized Official First Name:
SRI
Authorized Official Middle Name:
BHARAT
Authorized Official Title or Position:
C.E.O.
Authorized Official Telephone Number:
561-249-4317

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  CLF00340713 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: FU287A . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 05D2025713 . This is a "CLIA" identifier . This identifiers is of the category "OTHER".




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