MEDICARE: VERSA CARDIO LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	293D00000X	Physiological Laboratory
2	293D00000X	Physiological Laboratory	00050469	CA

General Provider Information

NPI Number	:	1366877508
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VERSA CARDIO LLC

Provider Business Mailing Address
First Line	:	255 E RINCON ST STE 210
Second Line	:
City	:	CORONA
State	:	CA
Zip	:	92879-1368
Country	:	US
Telephone Number	:	855-329-5794
Fax Number	:

Provider Business Practice Location Address
First Line	:	255 E RINCON ST STE 210
Second Line	:
City	:	CORONA
State	:	CA
Zip	:	92879-1368
Country	:	US
Telephone Number	:	855-329-5794
Fax Number	:	855-399-5796

Authorized Official
Title or Position	:	CEO
Name	:	DARIN SLACK
Credential	:
Telephone Number	:	855-329-5794

Provider Enumeration Date	:	09/06/2013
Last Update Date	:	06/05/2025

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