Provider Demographics
NPI:1619087988
Name:WAVECREST MEDICINE, INC.
Entity Type:Organization
Organization Name:WAVECREST MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KRIS
Authorized Official - Middle Name:C
Authorized Official - Last Name:KEALEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-985-0530
Mailing Address - Street 1:1850 SULLIVAN AVE
Mailing Address - Street 2:SUITE 320
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-2221
Mailing Address - Country:US
Mailing Address - Phone:650-985-0530
Mailing Address - Fax:650-985-0535
Practice Address - Street 1:1850 SULLIVAN AVE
Practice Address - Street 2:SUITE 320
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2221
Practice Address - Country:US
Practice Address - Phone:650-985-0530
Practice Address - Fax:650-985-0535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0101480Medicaid
CAG24082Medicare UPIN
CAGR0101480Medicaid