=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235727041
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEST WELL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2021
-----------------------------------------------------
Last Update Date | 01/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1233 SKI RUN BLVD # 4
-----------------------------------------------------
City | SOUTH LAKE TAHOE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96150-7495
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-556-4226
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5325 ELKHORN BLVD # 7081
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95842-2526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-556-4226
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | CHARLES BOLDWYN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 530-427-4163
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------