=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467103218
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VID TESTING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2022
-----------------------------------------------------
Last Update Date | 01/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 510 DEPTFORD AVE
-----------------------------------------------------
City | WESTVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08093-2236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-467-3080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 591 MUHLENBERG AVE
-----------------------------------------------------
City | WENONAH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08090-1348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-467-3080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BRIDGET OCONNOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-622-6496
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------