11D2119762 CLIA NUMBER - PLASTIC, HEAD AND NECK SURGERY INSTITUTE, LLC

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Laboratory Demographics

CLIA Number: 11D2119762

Facility Name: PLASTIC, HEAD AND NECK SURGERY INSTITUTE, LLC

Facility Address:
5730 GLENRIDGE DRIVE, SUITE T150
ATLANTA, GA
ZIP 30328
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Facility Phone Number: 404 256-5428

Facility Type: Ambulatory Surgery Center

Certificate Type: Waiver

NPI Number: 1295288751

Taxonomy: 261QA1903X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	11D2119762
LAB Type	Ambulatory Surgery Center
Facility Name	PLASTIC, HEAD AND NECK SURGERY INSTITUTE, LLC
Street	5730 GLENRIDGE DRIVE, SUITE T150
City	ATLANTA
State	GA
ZIP	30328
Phone	404 256-5428
CertificateType	4
CertificateEffectiveDate	10/4/2022
CertificateExpirationDate	10/3/2024
FacilityType	Waiver

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