11D2202711 CLIA NUMBER - PREMISE HEALTH OF GEORGIA MEDICAL, PC

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Laboratory Demographics

CLIA Number: 11D2202711

Facility Name: PREMISE HEALTH OF GEORGIA MEDICAL, PC

Facility Address:
1325 SATELLITE BOULEVARD BLDG 1100 SUITE 1110
SUWANEE, GA
ZIP 30024
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Facility Phone Number: 678 534-8055

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1346915220

Taxonomy: 261QM1300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	11D2202711
LAB Type	Physician Office
Facility Name	PREMISE HEALTH OF GEORGIA MEDICAL, PC
Street	1325 SATELLITE BOULEVARD BLDG 1100 SUITE 1110
City	SUWANEE
State	GA
ZIP	30024
Phone	678 534-8055
CertificateType	4
CertificateEffectiveDate	11/30/2022
CertificateExpirationDate	11/29/2024
FacilityType	Waiver

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This page was last updated on: 4/23/2024