MEDICARE: ELECTRONIC WAVEFORM LAB, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1679625677
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELECTRONIC WAVEFORM LAB, INC

Provider Business Mailing Address
First Line	:	5702 BOLSA AVE
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92649-1128
Country	:	US
Telephone Number	:	714-843-0463
Fax Number	:	714-500-4093

Provider Business Practice Location Address
First Line	:	5702 BOLSA AVE
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92649-1128
Country	:	US
Telephone Number	:	714-843-0463
Fax Number	:	714-500-4093

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. RYAN P HEANEY
Credential	:
Telephone Number	:	714-843-0463

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	09/28/2011

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