MEDICARE: MIRACOR DIAGNOSTICS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	293D00000X	Physiological Laboratory		CA

General Provider Information

NPI Number	:	1205943636
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIRACOR DIAGNOSTICS, INC.

Provider Business Mailing Address
First Line	:	3715 E SOUTH ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90805-4521
Country	:	US
Telephone Number	:	562-602-0700
Fax Number	:	562-602-0727

Provider Business Practice Location Address
First Line	:	3715 E SOUTH ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90805-4521
Country	:	US
Telephone Number	:	562-602-0700
Fax Number	:	562-602-0727

Authorized Official
Title or Position	:	CONTRACTING/CREDENTIALING SPECIALIS
Name	:	GAELANE ROSINSKI
Credential	:
Telephone Number	:	847-658-0996

Provider Enumeration Date	:	08/23/2006
Last Update Date	:	08/22/2020

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