Healthcare Provider Details

I. General information

NPI: 1104931864
Provider Name (Legal Business Name): MIRACOR DIAGNOSTICS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 E PACIFIC COAST HWY
LONG BEACH CA
90804-2112
US

IV. Provider business mailing address

445 W PARKVIEW TER
ALGONQUIN IL
60102-1950
US

V. Phone/Fax

Practice location:
  • Phone: 562-498-6322
  • Fax:
Mailing address:
  • Phone: 847-658-0996
  • Fax: 847-658-0991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number StateCA

VIII. Authorized Official

Name: GAELANE ROSINSKI
Title or Position: CONTRACTING/CREDENTIALING SPECIALIS
Credential: CPCS
Phone: 847658006