11D1099601 CLIA NUMBER - SOUTH GEORGIA PEDIATRICS PC

Laboratory Demographics

  • CLIA Code: 11D1099601
  • Facility Name: SOUTH GEORGIA PEDIATRICS PC
  • Facility Address: 1230 BRAMPTON AVENUE
    STATESBORO, GA
    ZIP 30458
  • Facility Phone: 912 489-5437
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: RAO IMMANENI
  • NPI Number: 1578797627
  • Taxonomy: 174400000X - Specialist

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CLIA Record

Field Name Field Value
CLIA Number 11D1099601
LAB Type Physician Office
Facility Name SOUTH GEORGIA PEDIATRICS PC
Street 1230 BRAMPTON AVENUE
City STATESBORO
State GA
ZIP 30458
Phone 912 489-5437
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 5/18/2025
Certificate Expiration Date 5/17/2027
Facility Type Physician Office
Lab Director RAO IMMANENI

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