11D2135589 CLIA NUMBER - GEORGIA RETINA, PC

Laboratory Demographics

  • CLIA Code: 11D2135589
  • Facility Name: GEORGIA RETINA, PC
  • Facility Address: 1462 MONTREAL ROAD, SUITE 412
    TUCKER, GA
    ZIP 30084
  • Facility Phone: 404 299-5209
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: MARK RIVELLESE
  • NPI Number: 1083177430
  • Taxonomy: 103K00000X - Behavior Analyst

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CLIA Record

Field Name Field Value
CLIA Number 11D2135589
LAB Type Physician Office
Facility Name GEORGIA RETINA, PC
Street 1462 MONTREAL ROAD, SUITE 412
City TUCKER
State GA
ZIP 30084
Phone 404 299-5209
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 8/24/2025
Certificate Expiration Date 8/23/2027
Facility Type Physician Office
Lab Director MARK RIVELLESE

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