Provider Demographics
NPI:1023765385
Name:EPICWAVE LABORATORY LLC
Entity type:Organization
Organization Name:EPICWAVE LABORATORY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARC BENEDICT
Authorized Official - Middle Name:ENRIQUEZ
Authorized Official - Last Name:BERNALDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MLS(ASCP)CM
Authorized Official - Phone:800-961-6747
Mailing Address - Street 1:16114 SHERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-3907
Mailing Address - Country:US
Mailing Address - Phone:800-961-6747
Mailing Address - Fax:
Practice Address - Street 1:16114 SHERMAN WAY
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-3907
Practice Address - Country:US
Practice Address - Phone:800-961-6747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-07
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
05D2308399OtherCLIA
CACLR-90006743OtherLABORATORY LICENSE
05D2262840OtherCLIA
CACDF-90013520OtherLABORATORY LICENSE