Healthcare Provider Details

I. General information

NPI: 1124306808
Provider Name (Legal Business Name): EPIGENESIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2011
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3390 UNIVERSITY AVE STE 640
RIVERSIDE CA
92501-3314
US

IV. Provider business mailing address

32158 CAMINO CAPISTRANO # A267
SAN JUAN CAPISTRANO CA
92675-3720
US

V. Phone/Fax

Practice location:
  • Phone: 951-744-4158
  • Fax: 951-742-5134
Mailing address:
  • Phone: 951-744-4158
  • Fax: 951-742-5134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number00G431511
License Number StateCA

VIII. Authorized Official

Name: A. J. ROGERS
Title or Position: CEO
Credential: M.D.
Phone: 951-744-4158