1770716441 NPI number — CORONA RADIATA LABS LLC

Table of content: (NPI 1770716441)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770716441 NPI number — CORONA RADIATA LABS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORONA RADIATA LABS LLC
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:
1770716441
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 HOLLAND STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92618-2568
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-588-2199
Provider Business Mailing Address Fax Number:
949-588-2199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1810 FULLERTON AVE # 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORONA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92881-3103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-246-7245
Provider Business Practice Location Address Fax Number:
818-246-7265
Provider Enumeration Date:
08/28/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DINSAY
Authorized Official First Name:
ROSELYN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
818-246-7245

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  G85448 , 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)