11D1017382 CLIA NUMBER - LOCUST GROVE FAMILY MEDICINE PC

Laboratory Demographics

CLIA Number: 11D1017382

Facility Name: LOCUST GROVE FAMILY MEDICINE PC

Facility Address:
3778 HIGHWAY 42
LOCUST GROVE, GA
ZIP 30248
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Facility Phone Number: 770 898-6054

Facility Type: Physician Office

Certificate Type: Microscopy

NPI Number: 1629169164

Taxonomy: 332900000X - Non-Pharmacy Dispensing Site
A site other than a pharmacy that dispenses medicinal preparations under the supervision of a physician to patients for self-administration. (e.g. physician offices, ER, Urgent Care Centers, Rural Health Facilities, etc.)

CLIA Record

Field Name	Field Value
CLIA Number	11D1017382
LAB Type	Physician Office
Facility Name	LOCUST GROVE FAMILY MEDICINE PC
Street	3778 HIGHWAY 42
City	LOCUST GROVE
State	GA
ZIP	30248
Phone	770 898-6054
CertificateType	3
CertificateEffectiveDate	9/24/2023
CertificateExpirationDate	9/23/2025
FacilityType	PPMP

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This page was last updated on: 4/23/2024