Provider Demographics
NPI:1104931864
Name:MIRACOR DIAGNOSTICS, INC.
Entity type:Organization
Organization Name:MIRACOR DIAGNOSTICS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTRACTING/CREDENTIALING SPECIALIS
Authorized Official - Prefix:
Authorized Official - First Name:GAELANE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:CPCS
Authorized Official - Phone:84-765-8006
Mailing Address - Street 1:445 W PARKVIEW TER
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-1950
Mailing Address - Country:US
Mailing Address - Phone:847-658-0996
Mailing Address - Fax:847-658-0991
Practice Address - Street 1:4200 E PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-2112
Practice Address - Country:US
Practice Address - Phone:562-498-6322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory