11D2144488 CLIA NUMBER - PROVIDENCE RD PRIMARY CARE

Laboratory Demographics

  • CLIA Code: 11D2144488
  • Facility Name: PROVIDENCE RD PRIMARY CARE
  • Facility Address: 4180 PROVIDENCE RD, SUITE 105
    MARIETTA, GA
    ZIP 30062
  • Facility Phone: 770 973-4749
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: AMMA ABUNYEWA
  • NPI Number: 1831537539
  • Taxonomy: 207R00000X - Internal Medicine

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CLIA Record

Field Name Field Value
CLIA Number 11D2144488
LAB Type Physician Office
Facility Name PROVIDENCE RD PRIMARY CARE
Street 4180 PROVIDENCE RD, SUITE 105
City MARIETTA
State GA
ZIP 30062
Phone 770 973-4749
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 2/19/2024
Certificate Expiration Date 2/18/2026
Facility Type Physician Office
Lab Director AMMA ABUNYEWA

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