Provider Demographics
NPI:1013912518
Name:EXPRESS DIAGNOSTICS, INC
Entity Type:Organization
Organization Name:EXPRESS DIAGNOSTICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAYEVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-783-6107
Mailing Address - Street 1:15130 VENTURA BLVD
Mailing Address - Street 2:STE 221
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-3372
Mailing Address - Country:US
Mailing Address - Phone:818-783-6107
Mailing Address - Fax:866-241-3280
Practice Address - Street 1:15130 VENTURA BLVD
Practice Address - Street 2:STE 221
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-3372
Practice Address - Country:US
Practice Address - Phone:818-783-6107
Practice Address - Fax:866-241-3280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA134513-57291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ08080ZOtherBLUE SHIELD OF CA
CAZZZ08080ZOtherBLUE SHIELD OF CA