=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497420814
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INFINITE DOT TESTING CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2021
-----------------------------------------------------
Last Update Date | 10/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6100 LAKE ELLENOR DR STE 151
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32809-4632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 833-463-8378
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 162943
-----------------------------------------------------
City | ALTAMONTE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32716-2943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DONIELLE TODMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 833-463-8378
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------