Provider Demographics
NPI:1336933274
Name:WGT GROUP LLC
Entity type:Organization
Organization Name:WGT GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LATONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:HANNIBAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-541-3353
Mailing Address - Street 1:815 SUPERIOR AVE E STE 1618
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114-2709
Mailing Address - Country:US
Mailing Address - Phone:866-238-8230
Mailing Address - Fax:
Practice Address - Street 1:815 SUPERIOR AVE E STE 1618
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44114-2709
Practice Address - Country:US
Practice Address - Phone:866-238-8230
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory