Provider Demographics
NPI:1669127346
Name:ILLUMINATE DIAGNOSTICS INC
Entity type:Organization
Organization Name:ILLUMINATE DIAGNOSTICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:KANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-403-1400
Mailing Address - Street 1:2670 N MAIN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-6639
Mailing Address - Country:US
Mailing Address - Phone:562-231-6828
Mailing Address - Fax:
Practice Address - Street 1:2670 N MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-6639
Practice Address - Country:US
Practice Address - Phone:562-231-6828
Practice Address - Fax:562-403-1401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-21
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory