=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225780042
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TESTING FOR COVID LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2022
-----------------------------------------------------
Last Update Date | 01/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1367 WIND ENERGY PASS
-----------------------------------------------------
City | BATAVIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60510-9007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-450-0006
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 118 SAINT GERMAIN PL
-----------------------------------------------------
City | SAINT CHARLES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60175-4607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-947-5066
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANGER
-----------------------------------------------------
Name | DYLAN HEINRICH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 630-947-5066
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------