Organization
EPICWAVE LABORATORY LLC
Active
Organization
EPICWAVE LABORATORY LLC
Active
Other names
EpicWave Laboratory
Organization subpart
No
Provider details
NPI number
Authorized official
MARC BENEDICT ENRIQUEZ BERNALDEZ MLS(ASCP)CM (OWNER)
(800) 961-6747
Entity
Organization
Contact information
Practice address
16114 SHERMAN WAY, VAN NUYS, CA 91406-3907
(800) 961-6747
Mailing address
16114 SHERMAN WAY, VAN NUYS, CA 91406-3907
(800) 961-6747
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
05D2262840
CLIA
—
01
—
05D2308399
CLIA
—
01
—
CDF-90013520
LABORATORY LICENSE
CA
01
—
CLR-90006743
LABORATORY LICENSE
CA
Enumeration date
03/07/2022
Last updated
08/09/2024
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