=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861153033
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOVA TESTING FACILITIES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2022
-----------------------------------------------------
Last Update Date | 01/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 140 W LAKE ST
-----------------------------------------------------
City | BLOOMINGDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60108-1020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 833-472-7438
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 140 W LAKE ST
-----------------------------------------------------
City | BLOOMINGDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60108-1020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 833-472-7438
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. GABRIEL POBLETE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 833-472-7438
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------