Healthcare Provider Details

I. General information

NPI: 1255764122
Provider Name (Legal Business Name): WAVE IMAGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2013
Last Update Date: 02/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25500 RANCHO NIGUEL RD SUITE 140
LAGUNA NIGUEL CA
92677-7302
US

IV. Provider business mailing address

17360 BROOKHURST ST
FOUNTAIN VALLEY CA
92708-3720
US

V. Phone/Fax

Practice location:
  • Phone: 949-362-3973
  • Fax: 949-362-3977
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARK D SCHAFER
Title or Position: MANAGER
Credential: MD
Phone: 657-241-3500