Organization
MITOMED DIAGNOSTICS LABORATORY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
PROF. DOUGLAS C. WALLACE PHD (LABORATORY DIRECTOR)
(949) 824-3490
Entity
Organization
Contact information
Practice address
2501 HEWITT HL, UNIVERSITY OF CALIFORNIA IRVINE, IRVINE, CA 92697-0001
(949) 824-1886
(949) 824-6388
Mailing address
2501 HEWITT HL, UNIVERSITY OF CALIFORNIA IRVINE, IRVINE, CA 92697-0001
(949) 824-1886
(949) 824-6388
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
05D1034314
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
05D1034314
CLIA
CA
Enumeration date
11/07/2008
Last updated
11/07/2008
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