11D2164528 CLIA NUMBER - LIVE OAK DERMATOLOGY

Laboratory Demographics

  • CLIA Code: 11D2164528
  • Facility Name: LIVE OAK DERMATOLOGY
  • Facility Address: 135 NORCROSS STREET
    ROSWELL, GA
    ZIP 30075
  • Facility Phone: 678 870-2020
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: BRENT T. GOEDJEN
  • NPI Number: 1194209163
  • Taxonomy: 207N00000X - Dermatology

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CLIA Record

Field Name Field Value
CLIA Number 11D2164528
LAB Type Physician Office
Facility Name LIVE OAK DERMATOLOGY
Street 135 NORCROSS STREET
City ROSWELL
State GA
ZIP 30075
Phone 678 870-2020
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 4/9/2025
Certificate Expiration Date 4/8/2027
Facility Type Physician Office
Lab Director BRENT T. GOEDJEN

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