11D2273257 CLIA NUMBER - BLACK SWAN LLC DBA LIV

Laboratory Demographics

  • CLIA Code: 11D2273257
  • Facility Name: BLACK SWAN LLC DBA LIV
  • Facility Address: 4625 ALEXANDER DRIVE, SUITE 200
    ALPHARETTA, GA
    ZIP 30022
  • Facility Phone: 404 513-5640
  • Facility Type: Comp. Outpatient Rehab Facility
  • Facility Type: Waiver
  • Lab Director: TODD WILSON
  • NPI Number: 1679275846
  • Taxonomy: 261QM0850X - Clinic/Center

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CLIA Record

Field Name Field Value
CLIA Number 11D2273257
LAB Type Comp. Outpatient Rehab Facility
Facility Name BLACK SWAN LLC DBA LIV
Street 4625 ALEXANDER DRIVE, SUITE 200
City ALPHARETTA
State GA
ZIP 30022
Phone 404 513-5640
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 12/9/2024
Certificate Expiration Date 12/8/2026
Facility Type Comp. Outpatient Rehab Facility
Lab Director TODD WILSON

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