11D2122676 CLIA NUMBER - PROVIDENT VILLAGE OF CREEKSIDE

Laboratory Demographics

  • CLIA Code: 11D2122676
  • Facility Name: PROVIDENT VILLAGE OF CREEKSIDE
  • Facility Address: 4838 SOUTH COBB DRIVE
    SMYRNA, GA
    ZIP 30080
  • Facility Phone: 678 903-0339
  • Facility Type: Assisted Living Facility
  • Facility Type: Waiver
  • Lab Director: ELAINE AUSTIN
  • NPI Number: 1891287645
  • Taxonomy: 310400000X - Assisted Living Facility

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CLIA Record

Field Name Field Value
CLIA Number 11D2122676
LAB Type Assisted Living Facility
Facility Name PROVIDENT VILLAGE OF CREEKSIDE
Street 4838 SOUTH COBB DRIVE
City SMYRNA
State GA
ZIP 30080
Phone 678 903-0339
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 12/5/2024
Certificate Expiration Date 12/4/2026
Facility Type Assisted Living Facility
Lab Director ELAINE AUSTIN

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