MEDICARE: ESSENCE OF TRUTH CLINICAL LAB, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1023760097
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ESSENCE OF TRUTH CLINICAL LAB, LLC

Provider Business Mailing Address
First Line	:	7034 N 55TH ST APT C
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53223-6336
Country	:	US
Telephone Number	:	414-405-9002
Fax Number	:

Provider Business Practice Location Address
First Line	:	4911 W GOOD HOPE RD STE D
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53223-4840
Country	:	US
Telephone Number	:	414-405-9002
Fax Number	:

Authorized Official
Title or Position	:	LAB DIRECTOR
Name	:	LATRINA KINGSBY
Credential	:	RN
Telephone Number	:	414-405-9002

Provider Enumeration Date	:	01/21/2022
Last Update Date	:	01/21/2022

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