=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366544025
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NATIONWIDE CARDIO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2006
-----------------------------------------------------
Last Update Date | 09/13/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16400 LOIS LN
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92504-5724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-776-7314
-----------------------------------------------------
Fax | 855-399-5796
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16400 LOIS LN
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92504-5724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-252-9700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DARIN SLACK
-----------------------------------------------------
Credential | IDTF
-----------------------------------------------------
Telephone | 951-776-7314
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 293D00000X
-----------------------------------------------------
Taxonomy Name | Physiological Laboratory
-----------------------------------------------------
License Number | 00050469
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------