Organization
FOURTH WALL TESTING LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. LISA WILSON (PRESIDENT)
(352) 630-0886
Entity
Organization
Contact information
Practice address
11705 JONES BRIDGE RD STE B101, JOHNS CREEK, GA 30005-5080
(678) 580-5908
Mailing address
712 S OCEAN SHORE BLVD # 217, FLAGLER BEACH, FL 32136-3602
(386) 693-1421
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
—
—
Other
Enumeration date
03/02/2022
Last updated
10/12/2022
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