11D1034360 CLIA NUMBER - LAKE HEARN DIALYSIS

Laboratory Demographics

CLIA Number: 11D1034360

Facility Name: LAKE HEARN DIALYSIS

Facility Address:
1150 LAKE HEARN DRIVE, SUITE 100 ATTN JENNIFER MAYA
ATLANTA, GA
ZIP 30342
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Facility Phone Number: 678 393-8144

Facility Type: End Stage Renal Disease Dialysis Facility

Certificate Type: Waiver

NPI Number: 1356657621

Taxonomy: 261QE0700X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	11D1034360
LAB Type	End Stage Renal Disease Dialysis Facility
Facility Name	LAKE HEARN DIALYSIS
Street	1150 LAKE HEARN DRIVE, SUITE 100 ATTN JENNIFER MAYA
City	ATLANTA
State	GA
ZIP	30342
Phone	678 393-8144
CertificateType	4
CertificateEffectiveDate	12/1/2022
CertificateExpirationDate	11/30/2024
FacilityType	Waiver

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