Healthcare Provider Details

I. General information

NPI: 1336933274
Provider Name (Legal Business Name): WGT GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 REASER CT STE 7
ELYRIA OH
44035-6285
US

IV. Provider business mailing address

123 REASER CT STE 7
ELYRIA OH
44035-6285
US

V. Phone/Fax

Practice location:
  • Phone: 440-616-2899
  • Fax: 440-458-4696
Mailing address:
  • Phone: 440-616-2899
  • Fax: 440-458-4696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: LATONYA HANNIBAL
Title or Position: OWNER
Credential:
Phone: 440-541-3353