Provider Demographics
NPI:1225390289
Name:EPISOURCE LLC
Entity Type:Organization
Organization Name:EPISOURCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SISHIR
Authorized Official - Middle Name:
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-452-1962
Mailing Address - Street 1:500 W 190TH ST
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-4268
Mailing Address - Country:US
Mailing Address - Phone:714-452-1961
Mailing Address - Fax:714-452-1966
Practice Address - Street 1:500 W 190TH ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4268
Practice Address - Country:US
Practice Address - Phone:714-452-1961
Practice Address - Fax:714-452-1966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-14
Last Update Date:2023-02-07
Deactivation Date:2022-12-14
Deactivation Code:
Reactivation Date:2023-02-07
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty