Provider Demographics
NPI:1831158757
Name:NEXTWAVE DIAGNOSTIC LABORATORIES, LLC
Entity type:Organization
Organization Name:NEXTWAVE DIAGNOSTIC LABORATORIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/ PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCKINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-202-2400
Mailing Address - Street 1:1915 S 17TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6626
Mailing Address - Country:US
Mailing Address - Phone:910-202-2400
Mailing Address - Fax:910-202-2499
Practice Address - Street 1:1915 S 17TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6626
Practice Address - Country:US
Practice Address - Phone:910-202-2400
Practice Address - Fax:910-202-2499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7001244Medicaid
NC7001244Medicaid