Provider Demographics
NPI:1851739619
Name:I2B LAB LLC
Entity Type:Organization
Organization Name:I2B LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GOWRIHARAN
Authorized Official - Middle Name:
Authorized Official - Last Name:THAIYANANTHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-376-6364
Mailing Address - Street 1:4631 TELLER AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-8105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4631 TELLER AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-8105
Practice Address - Country:US
Practice Address - Phone:949-335-7510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-13
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF 00344005291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory