=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356595011
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MITOMED DIAGNOSTICS LABORATORY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2008
-----------------------------------------------------
Last Update Date | 11/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2501 HEWITT HL UNIVERSITY OF CALIFORNIA IRVINE
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92697-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-824-1886
-----------------------------------------------------
Fax | 949-824-6388
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2501 HEWITT HL UNIVERSITY OF CALIFORNIA IRVINE
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92697-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-824-1886
-----------------------------------------------------
Fax | 949-824-6388
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LABORATORY DIRECTOR
-----------------------------------------------------
Name | PROF. DOUGLAS C. WALLACE
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 949-824-3490
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 05D1034314
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------