Provider Demographics
NPI:1982845640
Name:MED-SOURCE DIAGNOSTICS
Entity Type:Organization
Organization Name:MED-SOURCE DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:YVETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:CEJA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-955-1398
Mailing Address - Street 1:92 CORPORATE PARK
Mailing Address - Street 2:SUITE C226
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-5146
Mailing Address - Country:US
Mailing Address - Phone:959-955-1398
Mailing Address - Fax:949-861-7130
Practice Address - Street 1:92 CORPORATE PARK
Practice Address - Street 2:SUITE C226
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92606-5146
Practice Address - Country:US
Practice Address - Phone:959-955-1398
Practice Address - Fax:949-861-7130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-10
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABUS02/02209246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnosticGroup - Single Specialty