Provider Demographics
NPI:1942621560
Name:MYONSITE DIAGNOSTIC LAB
Entity Type:Organization
Organization Name:MYONSITE DIAGNOSTIC LAB
Other - Org Name:MYONSITE DIAGNOSTIC LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAYANK
Authorized Official - Middle Name:
Authorized Official - Last Name:TRIVEDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-881-5445
Mailing Address - Street 1:1990 MAIN ST STE 750
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34236-8000
Mailing Address - Country:US
Mailing Address - Phone:248-881-5445
Mailing Address - Fax:626-703-4620
Practice Address - Street 1:30211 AVENIDA DE LAS BANDERA STE 200
Practice Address - Street 2:
Practice Address - City:RANCHO SANTA MARGARITA
Practice Address - State:CA
Practice Address - Zip Code:92688-2159
Practice Address - Country:US
Practice Address - Phone:248-881-5445
Practice Address - Fax:626-703-4620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-27
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246RP1900X
CACLF 00345114291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty