MEDICARE: SAMPLE SAFE LABS

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	:	1790646933
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAMPLE SAFE LABS

Provider Business Mailing Address
First Line	:	8096 ELM DR STE 200D
Second Line	:
City	:	MECHANICSVILLE
State	:	VA
Zip	:	23111-1159
Country	:	US
Telephone Number	:	800-699-3060
Fax Number	:

Provider Business Practice Location Address
First Line	:	8096 ELM DR STE 200D
Second Line	:
City	:	MECHANICSVILLE
State	:	VA
Zip	:	23111-1159
Country	:	US
Telephone Number	:	800-699-3060
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ANGELA WYNN
Credential	:
Telephone Number	:	800-699-3060

Provider Enumeration Date	:	11/18/2025
Last Update Date	:	11/18/2025

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Directions to “SAMPLE SAFE LABS ” Practice Location

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