11D2081984 CLIA NUMBER - LOCUST GROVE DIALYSIS

Laboratory Demographics

  • CLIA Code: 11D2081984
  • Facility Name: LOCUST GROVE DIALYSIS
  • Facility Address: 521 STANLEY K TANGER BLVD
    LOCUST GROVE, GA
    ZIP 30248
  • Facility Phone: 770 914-1432
  • Facility Type: End Stage Renal Disease Dialysis Facility
  • Facility Type: Waiver
  • Lab Director: DEMETRIOUS BLACKMON
  • NPI Number: 1326456518
  • Taxonomy: 261QE0700X - Clinic/Center

Map and Directions

Get Directions

CLIA Record

Field Name Field Value
CLIA Number 11D2081984
LAB Type End Stage Renal Disease Dialysis Facility
Facility Name LOCUST GROVE DIALYSIS
Street 521 STANLEY K TANGER BLVD
City LOCUST GROVE
State GA
ZIP 30248
Phone 770 914-1432
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 8/5/2024
Certificate Expiration Date 8/4/2026
Facility Type End Stage Renal Disease Dialysis Facility
Lab Director DEMETRIOUS BLACKMON

Download Record

Download this CLIA record record in Text format: Export

Download this CLIA record record in Excel (CSV) format: Export

Download this CLIA record record in XML format: Export

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