11D2245972 CLIA NUMBER - PROACTIVE MD MISSION TO THE WORLD

Laboratory Demographics

CLIA Number: 11D2245972

Facility Name: PROACTIVE MD MISSION TO THE WORLD

Facility Address:
1600 N BROWN ROAD
LAWRENCEVILLE, GA
ZIP 30043
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Facility Phone Number: 678 527-7900

Facility Type: Practitioner Other

Certificate Type: Waiver

NPI Number: 1780340117

Taxonomy: 261QP2300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	11D2245972
LAB Type	Practitioner Other
Facility Name	PROACTIVE MD MISSION TO THE WORLD
Street	1600 N BROWN ROAD
City	LAWRENCEVILLE
State	GA
ZIP	30043
Phone	678 527-7900
CertificateType	4
CertificateEffectiveDate	12/20/2023
CertificateExpirationDate	12/19/2025
FacilityType	Waiver

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