Provider Demographics
NPI:1205524014
Name:MIRAGENEX LLC
Entity type:Organization
Organization Name:MIRAGENEX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMAD
Authorized Official - Middle Name:A
Authorized Official - Last Name:KHODAIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-669-1693
Mailing Address - Street 1:24 LITTLE FALLS RD STE E
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07004-1913
Mailing Address - Country:US
Mailing Address - Phone:347-669-1693
Mailing Address - Fax:516-753-9964
Practice Address - Street 1:125 MICHAEL DR STE 106
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-5311
Practice Address - Country:US
Practice Address - Phone:347-669-1693
Practice Address - Fax:516-753-9964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-28
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory