=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679625677
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELECTRONIC WAVEFORM LAB, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2007
-----------------------------------------------------
Last Update Date | 09/28/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5702 BOLSA AVE
-----------------------------------------------------
City | HUNTINGTON BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92649-1128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-843-0463
-----------------------------------------------------
Fax | 714-500-4093
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5702 BOLSA AVE
-----------------------------------------------------
City | HUNTINGTON BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92649-1128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-843-0463
-----------------------------------------------------
Fax | 714-500-4093
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. RYAN P HEANEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 714-843-0463
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------