MEDICARE: MAD SCIENCE LABORATORIES, LLC

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	291U00000X	Clinical Medical Laboratory	05D2080393	CA

General Provider Information

NPI Number	:	1801204482
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAD SCIENCE LABORATORIES, LLC

Provider Business Mailing Address
First Line	:	4223 GLENCOE AVE STE A130
Second Line	:
City	:	MARINA DEL REY
State	:	CA
Zip	:	90292-5887
Country	:	US
Telephone Number	:	310-625-1309
Fax Number	:	310-287-1949

Provider Business Practice Location Address
First Line	:	10401 VENICE BLVD
Second Line	:	270
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-6491
Country	:	US
Telephone Number	:	310-625-1309
Fax Number	:	310-287-1949

Authorized Official
Title or Position	:	CEO
Name	:	MICHAEL WELCH
Credential	:
Telephone Number	:	310-625-1309

Provider Enumeration Date	:	07/28/2014
Last Update Date	:	06/26/2025

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