11D2056076 CLIA NUMBER - INGLESIDE AVENUE - CLA HOME

Laboratory Demographics

  • CLIA Code: 11D2056076
  • Facility Name: INGLESIDE AVENUE - CLA HOME
  • Facility Address: 3090 INGESIDE AVENUE
    MACON, GA
    ZIP 31204
  • Facility Phone: 478 445-3336
  • Facility Type: Other - STATE-OPERATED CLA HOME
  • Facility Type: Waiver
  • Lab Director: MS. REBECCA HOLLOWAY
  • NPI Number: 1780712224
  • Taxonomy: 122300000X - Dentist

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CLIA Record

Field Name Field Value
CLIA Number 11D2056076
LAB Type Other - STATE-OPERATED CLA HOME
Facility Name INGLESIDE AVENUE - CLA HOME
Street 3090 INGESIDE AVENUE
City MACON
State GA
ZIP 31204
Phone 478 445-3336
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 3/21/2025
Certificate Expiration Date 3/20/2027
Facility Type Other - STATE-OPERATED CLA HOME
Lab Director MS. REBECCA HOLLOWAY

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