Healthcare Provider Details

I. General information

NPI: 1942621560
Provider Name (Legal Business Name): MYONSITE DIAGNOSTIC LAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2013
Last Update Date: 09/30/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30211 AVENIDA DE LAS BANDERA STE 200
RANCHO SANTA MARGARITA CA
92688-2159
US

IV. Provider business mailing address

1990 MAIN ST STE 750
SARASOTA FL
34236-8000
US

V. Phone/Fax

Practice location:
  • Phone: 248-881-5445
  • Fax: 626-703-4620
Mailing address:
  • Phone: 248-881-5445
  • Fax: 626-703-4620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberCLF 00345114
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State

VIII. Authorized Official

Name: MAYANK TRIVEDI
Title or Position: OWNER
Credential:
Phone: 248-881-5445