Provider Demographics
NPI:1124306808
Name:EPIGENESIS
Entity type:Organization
Organization Name:EPIGENESIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:A.
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-367-7600
Mailing Address - Street 1:P O BOX 7438
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92607-7438
Mailing Address - Country:US
Mailing Address - Phone:909-370-4400
Mailing Address - Fax:909-422-1588
Practice Address - Street 1:1550 E WASHINGTON ST
Practice Address - Street 2:SUITE ONE
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-4624
Practice Address - Country:US
Practice Address - Phone:909-370-4400
Practice Address - Fax:909-422-1588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-28
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00G431511208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFK802AMedicare PIN