Provider Demographics
NPI:1851049779
Name:TEST LIBERTY INC
Entity Type:Organization
Organization Name:TEST LIBERTY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MUKRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-204-3022
Mailing Address - Street 1:8241 LOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-2623
Mailing Address - Country:US
Mailing Address - Phone:833-542-8378
Mailing Address - Fax:
Practice Address - Street 1:2247 W DEVON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-2284
Practice Address - Country:US
Practice Address - Phone:833-542-8378
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-10
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory