MEDICARE: WGT GROUP 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	:	1336933274
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WGT GROUP LLC

Provider Business Mailing Address
First Line	:	815 SUPERIOR AVE E STE 1618
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44114-2709
Country	:	US
Telephone Number	:	866-238-8230
Fax Number	:

Provider Business Practice Location Address
First Line	:	815 SUPERIOR AVE E STE 1618
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44114-2709
Country	:	US
Telephone Number	:	866-238-8230
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LATONYA HANNIBAL
Credential	:
Telephone Number	:	440-541-3353

Provider Enumeration Date	:	04/07/2025
Last Update Date	:	04/07/2025

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Directions to “WGT GROUP LLC ” Practice Location

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