MEDICARE: SUN DIAGNOSTIC

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

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	TG070	OTHER	CA	MEDICARE PROVIDER NUMBER

General Provider Information

NPI Number	:	1982717963
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUN DIAGNOSTIC

Provider Business Mailing Address
First Line	:	425 S FAIRFAX AVE
Second Line	:	SUITE 308
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-3148
Country	:	US
Telephone Number	:	323-934-9873
Fax Number	:

Provider Business Practice Location Address
First Line	:	425 S FAIRFAX AVE
Second Line	:	SUITE 308
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-3148
Country	:	US
Telephone Number	:	323-934-9873
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ELEONORA KIRNOS
Credential	:
Telephone Number	:	323-934-9873

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	08/22/2020

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Directions to “SUN DIAGNOSTIC ” Practice Location

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