Healthcare Provider Details

I. General information

NPI: 1962460071
Provider Name (Legal Business Name): FIDELIS DIAGNOSTICS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 07/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11601 WILSHIRE BLVD SUITE 500
LOS ANGELES CA
90025-0509
US

IV. Provider business mailing address

11601 WILSHIRE BLVD SUITE 500
LOS ANGELES CA
90025-0509
US

V. Phone/Fax

Practice location:
  • Phone: 877-408-2488
  • Fax: 866-776-6641
Mailing address:
  • Phone: 877-408-2488
  • Fax: 866-776-6641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name: MARK DORNER
Title or Position: COO
Credential:
Phone: 877-408-2488