Provider Demographics
NPI:1679625677
Name:ELECTRONIC WAVEFORM LAB, INC
Entity type:Organization
Organization Name:ELECTRONIC WAVEFORM LAB, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:HEANEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-843-0463
Mailing Address - Street 1:5702 BOLSA AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-1128
Mailing Address - Country:US
Mailing Address - Phone:714-843-0463
Mailing Address - Fax:714-500-4093
Practice Address - Street 1:5702 BOLSA AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649-1128
Practice Address - Country:US
Practice Address - Phone:714-843-0463
Practice Address - Fax:714-500-4093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies