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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