11D2273257 CLIA NUMBER - BLACK SWAN LLC DBA LIV

Laboratory Demographics

CLIA Number: 11D2273257

Facility Name: BLACK SWAN LLC DBA LIV

Facility Address:
11030 JONES BRIDGE ROAD, SUITE 300
JOHNS CREEK, GA
ZIP 30022
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Facility Phone Number: 404 513-5640

Facility Type: Comp. Outpatient Rehab Facility

Certificate Type: Waiver

NPI Number: 1679275846

Taxonomy: 261QM0850X - Clinic/Center
An entity, facility, or distinct part of a facility providing diagnostic, treatment, and prescriptive services related to mental and behavioral disorders in adults.

CLIA Record

Field Name	Field Value
CLIA Number	11D2273257
LAB Type	Comp. Outpatient Rehab Facility
Facility Name	BLACK SWAN LLC DBA LIV
Street	11030 JONES BRIDGE ROAD, SUITE 300
City	JOHNS CREEK
State	GA
ZIP	30022
Phone	404 513-5640
CertificateType	4
CertificateEffectiveDate	12/9/2022
CertificateExpirationDate	12/8/2024
FacilityType	Waiver

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