11D1072745 CLIA NUMBER - LOCUST GROVE ENDO CENTER

Laboratory Demographics

  • CLIA Code: 11D1072745
  • Facility Name: LOCUST GROVE ENDO CENTER
  • Facility Address: 4865 BILL GARDNER PARKWAY
    LOCUST GROVE, GA
    ZIP 30248
  • Facility Phone: 770 692-0100
  • Facility Type: Ambulatory Surgery Center
  • Facility Type: Waiver
  • Lab Director: JAY PRAKASH
  • NPI Number: 1023134640
  • Taxonomy: 261QA1903X - Clinic/Center

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CLIA Record

Field Name Field Value
CLIA Number 11D1072745
LAB Type Ambulatory Surgery Center
Facility Name LOCUST GROVE ENDO CENTER
Street 4865 BILL GARDNER PARKWAY
City LOCUST GROVE
State GA
ZIP 30248
Phone 770 692-0100
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 8/23/2025
Certificate Expiration Date 8/22/2027
Facility Type Ambulatory Surgery Center
Lab Director JAY PRAKASH

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This page was last updated on: 9/29/2025