MEDICARE: TEST WELL, 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	:	1235727041
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TEST WELL, LLC

Provider Business Mailing Address
First Line	:	5325 ELKHORN BLVD # 7081
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95842-2526
Country	:	US
Telephone Number	:	530-556-4226
Fax Number	:

Provider Business Practice Location Address
First Line	:	1233 SKI RUN BLVD # 4
Second Line	:
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96150-7495
Country	:	US
Telephone Number	:	530-556-4226
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	CHARLES BOLDWYN
Credential	:
Telephone Number	:	530-427-4163

Provider Enumeration Date	:	01/07/2021
Last Update Date	:	01/12/2021

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Directions to “TEST WELL, LLC ” Practice Location

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