11D2131205 CLIA NUMBER - PROACTIVE PHYSICIANS OF MARIETTA, PC

Laboratory Demographics

CLIA Number: 11D2131205

Facility Name: PROACTIVE PHYSICIANS OF MARIETTA, PC

Facility Address:
790 CHURCH STREET, SUITE 220
MARIETTA, GA
ZIP 30060
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Facility Phone Number: 678 753-9300

Facility Type: Physician Office

Certificate Type: Microscopy

NPI Number: 1003356361

Taxonomy: 261QP2300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	11D2131205
LAB Type	Physician Office
Facility Name	PROACTIVE PHYSICIANS OF MARIETTA, PC
Street	790 CHURCH STREET, SUITE 220
City	MARIETTA
State	GA
ZIP	30060
Phone	678 753-9300
CertificateType	3
CertificateEffectiveDate	5/24/2023
CertificateExpirationDate	5/23/2025
FacilityType	PPMP

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