11D2200431 CLIA NUMBER - SOUTHERN CORRECTIONAL MEDICINE, LLC

Laboratory Demographics

  • CLIA Code: 11D2200431
  • Facility Name: SOUTHERN CORRECTIONAL MEDICINE, LLC
  • Facility Address: 145 JOHNSON AVENUE
    FAYETTEVILLE, GA
    ZIP 30214
  • Facility Phone: 912 283-5260
  • Facility Type: Other - JAIL
  • Facility Type: Waiver
  • Lab Director: PETER WROBEL
  • NPI Number: 1568861268
  • Taxonomy: 208600000X - Surgery

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CLIA Record

Field Name Field Value
CLIA Number 11D2200431
LAB Type Other - JAIL
Facility Name SOUTHERN CORRECTIONAL MEDICINE, LLC
Street 145 JOHNSON AVENUE
City FAYETTEVILLE
State GA
ZIP 30214
Phone 912 283-5260
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 11/16/2024
Certificate Expiration Date 11/15/2026
Facility Type Other - JAIL
Lab Director PETER WROBEL

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