11D1074084 CLIA NUMBER - GEORGIA MOUNTAIN DERMATOLOGY, LLC

Laboratory Demographics

  • CLIA Code: 11D1074084
  • Facility Name: GEORGIA MOUNTAIN DERMATOLOGY, LLC
  • Facility Address: 150 INTERSTATE SOUTH DRIVE SUITE 100
    JASPER, GA
    ZIP 30143
  • Facility Phone: 706 253-3376
  • Facility Type: Physician Office
  • Facility Type: Microscopy
  • Lab Director: SR. CARLTON T. FAULK
  • NPI Number: 1043400088
  • Taxonomy: 207N00000X - Dermatology

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CLIA Record

Field Name Field Value
CLIA Number 11D1074084
LAB Type Physician Office
Facility Name GEORGIA MOUNTAIN DERMATOLOGY, LLC
Street 150 INTERSTATE SOUTH DRIVE SUITE 100
City JASPER
State GA
ZIP 30143
Phone 706 253-3376
Certificate Type Certificate for Provider-Performed Microscopy Procedures (PPMP)
Certificate Type Description This certificate is issued to a laboratory in which a physician, midlevel practitioner or dentist performs no tests other than the microscopy procedures. This certificate permits the laboratory to also perform waived tests.
Certificate Effective Date 8/1/2024
Certificate Expiration Date 7/31/2026
Facility Type Physician Office
Lab Director SR. CARLTON T. FAULK

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