11D1062045 CLIA NUMBER - MOUNTAIN PARK DIALYSIS

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Laboratory Demographics

CLIA Number: 11D1062045

Facility Name: MOUNTAIN PARK DIALYSIS

Facility Address:
5235 MEMORIAL DRIVE
STONE MOUNTAIN, GA
ZIP 30083
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Facility Phone Number: 404 296-1344

Facility Type: End Stage Renal Disease Dialysis Facility

Certificate Type: Waiver

NPI Number: 1093808834

Taxonomy: 261QE0700X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	11D1062045
LAB Type	End Stage Renal Disease Dialysis Facility
Facility Name	MOUNTAIN PARK DIALYSIS
Street	5235 MEMORIAL DRIVE
City	STONE MOUNTAIN
State	GA
ZIP	30083
Phone	404 296-1344
CertificateType	4
CertificateEffectiveDate	12/5/2022
CertificateExpirationDate	12/4/2024
FacilityType	Waiver

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