Healthcare Provider Details

I. General information

NPI: 1114347978
Provider Name (Legal Business Name): TESTFORTHAT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 04/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 BRENDAN WAY
GREENVILLE SC
29615-3515
US

IV. Provider business mailing address

210 BRENDAN WAY
GREENVILLE SC
29615-3515
US

V. Phone/Fax

Practice location:
  • Phone: 864-990-4189
  • Fax:
Mailing address:
  • Phone: 864-990-4189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State

VIII. Authorized Official

Name: MR. THOMAS ANDRES CANIPE
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 864-325-9694