11D1010647 CLIA NUMBER - KENNESAW PEDIATRICS PC

Laboratory Demographics

  • CLIA Code: 11D1010647
  • Facility Name: KENNESAW PEDIATRICS PC
  • Facility Address: 3745 CHEROKEE STREET, SUITE 401
    KENNESAW, GA
    ZIP 30144
  • Facility Phone: 770 429-1005
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: MARK A. LONG
  • NPI Number: 1659565562
  • Taxonomy: 261QP2300X - Clinic/Center

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CLIA Record

Field Name Field Value
CLIA Number 11D1010647
LAB Type Physician Office
Facility Name KENNESAW PEDIATRICS PC
Street 3745 CHEROKEE STREET, SUITE 401
City KENNESAW
State GA
ZIP 30144
Phone 770 429-1005
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 6/1/2023
Certificate Expiration Date 5/31/2025
Facility Type Physician Office
Lab Director MARK A. LONG

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This page was last updated on: 3/20/2025