MEDICARE: EPICGENETICS, 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	291U00000X	Clinical Medical Laboratory	CLF 00343424	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CLF00343424	OTHER	CA	CLIA

General Provider Information

NPI Number	:	1639588890
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EPICGENETICS, INC.

Provider Business Mailing Address
First Line	:	11801 W OLYMPIC BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-1114
Country	:	US
Telephone Number	:	310-268-1001
Fax Number	:	310-552-1940

Provider Business Practice Location Address
First Line	:	11801 W OLYMPIC BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-1114
Country	:	US
Telephone Number	:	310-268-1001
Fax Number	:	310-268-1015

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BRUCE S GILLIS
Credential	:	M.D., M.P.H.
Telephone Number	:	310-268-1001

Provider Enumeration Date	:	08/12/2014
Last Update Date	:	02/06/2019

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Directions to “EPICGENETICS, INC. ” Practice Location

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