11D2273531 CLIA NUMBER - ANNUAL MEDICARE WELLNESS EXAMS

Laboratory Demographics

CLIA Number: 11D2273531

Facility Name: ANNUAL MEDICARE WELLNESS EXAMS

Facility Address:
1880 BRASELTON HIGHWAY, SUITE 118
LAWRENCEVILLE, GA
ZIP 30043
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Facility Phone Number: 706 761-6553

Facility Type: Independent

Certificate Type: Waiver

NPI Number: 1164148755

Taxonomy: 261QH0100X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	11D2273531
LAB Type	Independent
Facility Name	ANNUAL MEDICARE WELLNESS EXAMS
Street	1880 BRASELTON HIGHWAY, SUITE 118
City	LAWRENCEVILLE
State	GA
ZIP	30043
Phone	706 761-6553
CertificateType	4
CertificateEffectiveDate	12/14/2022
CertificateExpirationDate	12/13/2024
FacilityType	Waiver

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