Provider Demographics
NPI:1093149197
Name:WAVE IMAGING, LLC
Entity Type:Organization
Organization Name:WAVE IMAGING, LLC
Other - Org Name:MEMORIALCARE IMAGING CENTER-LAGUNA NIGUEL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:SCHAFER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:657-241-3500
Mailing Address - Street 1:17360 BROOKHURST ST
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-3720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25500 RANCHO NIGUEL RD
Practice Address - Street 2:SUITE 120
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-7302
Practice Address - Country:US
Practice Address - Phone:949-362-3973
Practice Address - Fax:949-362-3977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-26
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB206287Medicare PIN