Basic Information
| Provider Information | |||||||||
| NPI: | 1689327603 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NU WAVE NDT INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1108 N ANGELENO AVE # 911 | ||||||||
| Address2: | |||||||||
| City: | AZUSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917021913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262241287 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1720 E. CESAR CHAVEZ AVENUE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232685000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2022 | ||||||||
| LastUpdateDate: | 01/31/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BAENA | ||||||||
| AuthorizedOfficialFirstName: | ROCIO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INTRAOPERATIVENEUROMONITORIST | ||||||||
| AuthorizedOfficialTelephone: | 6262241287 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NU WAVE NDT INC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | R. EEG., CNIM, BS | ||||||||
| NPICertificationDate: | 01/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 17001125572 | 01 | CA | NPI 1 | OTHER | 17001125572 | 01 | CA | NPI | OTHER |