11D1093939 CLIA NUMBER - PONCE PRIMARY CARE

Laboratory Demographics

  • CLIA Code: 11D1093939
  • Facility Name: PONCE PRIMARY CARE
  • Facility Address: 315 W PONCE DE LEON AVENUE, SUITE 110
    DECATUR, GA
    ZIP 30030
  • Facility Phone: 404 537-2521
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: CHAD D. COSTLEY
  • NPI Number: 1477865681
  • Taxonomy: 261QP2300X - Clinic/Center

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CLIA Record

Field Name Field Value
CLIA Number 11D1093939
LAB Type Physician Office
Facility Name PONCE PRIMARY CARE
Street 315 W PONCE DE LEON AVENUE, SUITE 110
City DECATUR
State GA
ZIP 30030
Phone 404 537-2521
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 1/6/2025
Certificate Expiration Date 1/5/2027
Facility Type Physician Office
Lab Director CHAD D. COSTLEY

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