Basic Information
| Provider Information | |||||||||
| NPI: | 1225390289 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EPISOURCE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 W 190TH ST | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | GARDENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902484268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144521961 | ||||||||
| FaxNumber: | 7144521966 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W 190TH ST | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | GARDENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902484268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144521961 | ||||||||
| FaxNumber: | 7144521966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2012 | ||||||||
| LastUpdateDate: | 07/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | REDDY | ||||||||
| AuthorizedOfficialFirstName: | SISHIR | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7144521962 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 07/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.