MEDICARE: MOBILE COVID TESTING 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	45D2216881	OTHER	TX	CLIA

General Provider Information

NPI Number	:	1942883855
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOBILE COVID TESTING LLC

Provider Business Mailing Address
First Line	:	5726 DUMFRIES DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77096-4819
Country	:	US
Telephone Number	:	832-402-7812
Fax Number	:

Provider Business Practice Location Address
First Line	:	5726 DUMFRIES DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77096-4819
Country	:	US
Telephone Number	:	214-400-3130
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SHMUEL ROTTMAN
Credential	:
Telephone Number	:	214-400-3130

Provider Enumeration Date	:	04/29/2021
Last Update Date	:	08/14/2021

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