11D2115952 CLIA NUMBER - PREMISE HEALTH OF GEORGIA MEDICAL, PC

Laboratory Demographics

CLIA Number: 11D2115952

Facility Name: PREMISE HEALTH OF GEORGIA MEDICAL, PC

Facility Address:
1001 JOHNSON FERRY RD NE
ATLANTA, GA
ZIP 30342
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Facility Phone Number: 404 785-4258

Facility Type: Other - ONSITE EMPLOYEE HEALTH

Certificate Type: Waiver

NPI Number: 1093178147

Taxonomy: 261QM1300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	11D2115952
LAB Type	Other - ONSITE EMPLOYEE HEALTH
Facility Name	PREMISE HEALTH OF GEORGIA MEDICAL, PC
Street	1001 JOHNSON FERRY RD NE
City	ATLANTA
State	GA
ZIP	30342
Phone	404 785-4258
CertificateType	4
CertificateEffectiveDate	7/15/2022
CertificateExpirationDate	7/14/2024
FacilityType	Waiver

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