Provider Demographics
NPI:1235727041
Name:TEST WELL, LLC
Entity Type:Organization
Organization Name:TEST WELL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLDWYN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-427-4163
Mailing Address - Street 1:5325 ELKHORN BLVD # 7081
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95842-2526
Mailing Address - Country:US
Mailing Address - Phone:530-556-4226
Mailing Address - Fax:
Practice Address - Street 1:1233 SKI RUN BLVD # 4
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-7495
Practice Address - Country:US
Practice Address - Phone:530-556-4226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-07
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory