=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801204482
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAD SCIENCE LABORATORIES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2014
-----------------------------------------------------
Last Update Date | 06/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10401 VENICE BLVD 270
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90034-6491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-625-1309
-----------------------------------------------------
Fax | 310-287-1949
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4223 GLENCOE AVE STE A130
-----------------------------------------------------
City | MARINA DEL REY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90292-5887
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-625-1309
-----------------------------------------------------
Fax | 310-287-1949
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MICHAEL WELCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-625-1309
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 05D2080393
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------