Healthcare Provider Details

I. General information

NPI: 1174276844
Provider Name (Legal Business Name): PERSONAL SPACE TESTING EAST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2022
Last Update Date: 02/01/2022
Certification Date: 02/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 WALL ST STE 3350
NEW YORK NY
10005-4301
US

IV. Provider business mailing address

1212 STANFORD AVE STE 106
LOS ANGELES CA
90021-2157
US

V. Phone/Fax

Practice location:
  • Phone: 310-999-9824
  • Fax:
Mailing address:
  • Phone: 310-999-9824
  • Fax: 310-861-1599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AUSTIN L YOUNG
Title or Position: CEO
Credential:
Phone: 310-999-9824