Provider Demographics
NPI:1891178273
Name:WAVE IMAGING LLC
Entity Type:Organization
Organization Name:WAVE IMAGING LLC
Other - Org Name:MEMORIALCARE IMAGING CENTER-SAN CLEMENTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
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:657-241-3500
Mailing Address - Fax:
Practice Address - Street 1:675 CAMINO DE LOS MARES
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2835
Practice Address - Country:US
Practice Address - Phone:949-493-8799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-03
Last Update Date:2015-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology