=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407264500
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIBRANT AMERICA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2014
-----------------------------------------------------
Last Update Date | 01/13/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1021 HOWARD AVENUE SUITE B
-----------------------------------------------------
City | SAN CARLOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94070-4034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-830-5575
-----------------------------------------------------
Fax | 650-508-8260
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1021 HOWARD AVENUE SUITE B
-----------------------------------------------------
City | SAN CARLOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94070-4034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-830-5575
-----------------------------------------------------
Fax | 650-508-8260
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JOHN JAGAZEEL RAJASEKARAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 408-203-9383
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | CLF 00346278
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------