=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851739619
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | I2B LAB LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2013
-----------------------------------------------------
Last Update Date | 06/13/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4631 TELLER AVE SUITE 100
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-8105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-335-7510
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4631 TELLER AVE SUITE 100
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-8105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GOWRIHARAN THAIYANANTHAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 203-376-6364
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | CLF 00344005
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------