Healthcare Provider Details

I. General information

NPI: 1225390289
Provider Name (Legal Business Name): EPISOURCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2012
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date: 12/14/2022
Reactivation Date: 02/07/2023

III. Provider practice location address

500 W 190TH ST 4TH FLOOR
GARDENA CA
90248-4268
US

IV. Provider business mailing address

500 W 190TH ST 4TH FLOOR
GARDENA CA
90248-4268
US

V. Phone/Fax

Practice location:
  • Phone: 714-452-1961
  • Fax: 714-452-1966
Mailing address:
  • Phone: 714-452-1961
  • Fax: 714-452-1966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. SISHIR REDDY
Title or Position: CEO
Credential:
Phone: 714-452-1962