Healthcare Provider Details

I. General information

NPI: 1003089970
Provider Name (Legal Business Name): MEDARDO SUPNET M.D. INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2008
Last Update Date: 04/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3585 E IMPERIAL HWY
LYNWOOD CA
90262-2654
US

IV. Provider business mailing address

3585 E IMPERIAL HWY
LYNWOOD CA
90262-2654
US

V. Phone/Fax

Practice location:
  • Phone: 310-605-4260
  • Fax: 310-605-4263
Mailing address:
  • Phone: 310-605-4260
  • Fax: 310-605-4263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberA46203
License Number StateCA

VIII. Authorized Official

Name: MELIZA DAYRIT
Title or Position: OFFICE MANAGER
Credential:
Phone: 310-605-4260