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General NPI Number Information
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NPI Number | 1205524014
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Entity Type | Organization
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Legal Business Name | MIRAGENEX LLC
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Dates
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Enumeration Date | 04/28/2023
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Last Update Date | 04/28/2023
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Provider Practice Location Address
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Address Line | 125 MICHAEL DR STE 106
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City | SYOSSET
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State | NY
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Zip | 11791-5311
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Country | US
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Telephone | 347-669-1693
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Fax | 516-753-9964
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Provider Business Mailing Address
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Address Line | 24 LITTLE FALLS RD STE E
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City | FAIRFIELD
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State | NJ
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Zip | 07004-1913
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Country | US
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Telephone | 347-669-1693
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Fax | 516-753-9964
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Authorized Official
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Title or Position | OWNER
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Name | MOHAMAD A KHODAIR
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Credential | MD
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Telephone | 347-669-1693
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State |
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