Healthcare Provider Details

I. General information

NPI: 1134699945
Provider Name (Legal Business Name): EXECUTIVE DIAGNOSTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2018
Last Update Date: 12/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5455 EXECUTIVE PL STE B
JACKSON MS
39206-4104
US

IV. Provider business mailing address

10996 FOUR SEASONS PL STE 100A
CROWN POINT IN
46307-8685
US

V. Phone/Fax

Practice location:
  • Phone: 219-395-0667
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: DR. KIRNJOT SINGH
Title or Position: PRESIDENT
Credential: MD
Phone: 219-395-0667