Provider Demographics
NPI:1801204482
Name:MAD SCIENCE, LLC
Entity Type:Organization
Organization Name:MAD SCIENCE, LLC
Other - Org Name:REHAB LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WELCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-625-1309
Mailing Address - Street 1:10401 VENICE BLVD
Mailing Address - Street 2:270
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-6491
Mailing Address - Country:US
Mailing Address - Phone:310-625-1309
Mailing Address - Fax:310-287-1949
Practice Address - Street 1:10401 VENICE BLVD
Practice Address - Street 2:270
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-6491
Practice Address - Country:US
Practice Address - Phone:310-625-1309
Practice Address - Fax:310-287-1949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-28
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05D2080393291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory