11D2115631 CLIA NUMBER - PONCE DE LEON SURGERY CENTER, LLC

Laboratory Demographics

CLIA Number: 11D2115631

Facility Name: PONCE DE LEON SURGERY CENTER, LLC

Facility Address:
552 PONCE DE LEON AVE
ATLANTA, GA
ZIP 30308
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Facility Phone Number: 404 343-2672

Facility Type: Ambulatory Surgery Center

Certificate Type: Waiver

NPI Number: 1740738095

Taxonomy: 261QA1903X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	11D2115631
LAB Type	Ambulatory Surgery Center
Facility Name	PONCE DE LEON SURGERY CENTER, LLC
Street	552 PONCE DE LEON AVE
City	ATLANTA
State	GA
ZIP	30308
Phone	404 343-2672
CertificateType	4
CertificateEffectiveDate	7/12/2022
CertificateExpirationDate	7/11/2024
FacilityType	Waiver

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This page was last updated on: 4/23/2024