Provider Demographics
NPI:1134405012
Name:EPINEX DIAGNOSTICS LABORATORIES, INC.
Entity type:Organization
Organization Name:EPINEX DIAGNOSTICS LABORATORIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:
Authorized Official - First Name:SRI
Authorized Official - Middle Name:BHARAT
Authorized Official - Last Name:MADIREDDY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:561-249-4317
Mailing Address - Street 1:14351 MYFORD RD
Mailing Address - Street 2:SUITE K
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-7074
Mailing Address - Country:US
Mailing Address - Phone:949-464-5682
Mailing Address - Fax:714-731-7229
Practice Address - Street 1:14351 MYFORD RD
Practice Address - Street 2:SUITE K
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-7074
Practice Address - Country:US
Practice Address - Phone:949-464-5682
Practice Address - Fax:714-731-1229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-24
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF00340713291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FU287AOtherMEDICARE PTAN
05D2025713OtherCLIA