11D2130828 CLIA NUMBER - PCA INTERVENTIONAL SPINE AT FAYETTE, LLC

Laboratory Demographics

CLIA Number: 11D2130828

Facility Name: PCA INTERVENTIONAL SPINE AT FAYETTE, LLC

Facility Address:
1233 HIGHWAY 54 WEST, SUITE 205
FAYETTEVILLE, GA
ZIP 30214
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Facility Phone Number: 404 351-7654

Facility Type: Ambulatory Surgery Center

Certificate Type: Waiver

NPI Number: 1447791074

Taxonomy: 261QP3300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	11D2130828
LAB Type	Ambulatory Surgery Center
Facility Name	PCA INTERVENTIONAL SPINE AT FAYETTE, LLC
Street	1233 HIGHWAY 54 WEST, SUITE 205
City	FAYETTEVILLE
State	GA
ZIP	30214
Phone	404 351-7654
CertificateType	4
CertificateEffectiveDate	5/18/2023
CertificateExpirationDate	5/17/2025
FacilityType	Waiver

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