Provider Demographics
NPI:1770230492
Name:FOURTH WALL TESTING LLC
Entity Type:Organization
Organization Name:FOURTH WALL TESTING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-630-0886
Mailing Address - Street 1:712 S OCEAN SHORE BLVD # 217
Mailing Address - Street 2:
Mailing Address - City:FLAGLER BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32136-3602
Mailing Address - Country:US
Mailing Address - Phone:386-693-1421
Mailing Address - Fax:
Practice Address - Street 1:11705 JONES BRIDGE RD STE B101
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30005-5080
Practice Address - Country:US
Practice Address - Phone:678-580-5908
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-02
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory