11D2178274 CLIA NUMBER - IVYDALE WELLNESS CENTER

Laboratory Demographics

  • CLIA Code: 11D2178274
  • Facility Name: IVYDALE WELLNESS CENTER
  • Facility Address: 881 IVYDALE LANE
    LAWRENCEVILLE, GA
    ZIP 30045
  • Facility Phone: 404 819-8701
  • Facility Type: Practitioner Other
  • Facility Type: Waiver
  • Lab Director: ABLAVI A. AGOMESSOU
  • NPI Number: 1659919066
  • Taxonomy: 363LP0808X - Nurse Practitioner

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CLIA Record

Field Name Field Value
CLIA Number 11D2178274
LAB Type Practitioner Other
Facility Name IVYDALE WELLNESS CENTER
Street 881 IVYDALE LANE
City LAWRENCEVILLE
State GA
ZIP 30045
Phone 404 819-8701
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 1/30/2024
Certificate Expiration Date 1/29/2026
Facility Type Practitioner Other
Lab Director ABLAVI A. AGOMESSOU

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