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General NPI Number Information
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NPI Number | 1770230492
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Entity Type | Organization
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Legal Business Name | FOURTH WALL TESTING LLC
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Dates
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Enumeration Date | 03/02/2022
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Last Update Date | 10/12/2022
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Provider Practice Location Address
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Address Line | 11705 JONES BRIDGE RD STE B101
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City | JOHNS CREEK
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State | GA
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Zip | 30005-5080
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Country | US
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Telephone | 678-580-5908
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Fax |
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Provider Business Mailing Address
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Address Line | 712 S OCEAN SHORE BLVD # 217
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City | FLAGLER BEACH
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State | FL
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Zip | 32136-3602
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Country | US
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Telephone | 386-693-1421
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MRS. LISA WILSON
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Credential |
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Telephone | 352-630-0886
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State |
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