=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760136105
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICAL TESTERS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2022
-----------------------------------------------------
Last Update Date | 03/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 137 MAGNAVIEW DR
-----------------------------------------------------
City | MCDONOUGH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30253-3039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-216-7352
-----------------------------------------------------
Fax | 404-393-0703
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 137 MAGNAVIEW DR
-----------------------------------------------------
City | MCDONOUGH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30253-3039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-216-7352
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | BASHAH T GAINES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 321-216-7352
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171400000X
-----------------------------------------------------
Taxonomy Name | Health & Wellness Coach
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------