11D2322041 CLIA NUMBER - BOUTIQUE GYN WELLNESS CENTER

Laboratory Demographics

  • CLIA Code: 11D2322041
  • Facility Name: BOUTIQUE GYN WELLNESS CENTER
  • Facility Address: 2970 CLAIRMONT ROAD, NE, SUITE 903
    ATLANTA, GA
    ZIP 30329
  • Facility Phone: 404 344-0003
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: FONDA D. MARTIN
  • NPI Number: 1457187742
  • Taxonomy: 207VG0400X - Obstetrics & Gynecology

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CLIA Record

Field Name Field Value
CLIA Number 11D2322041
LAB Type Physician Office
Facility Name BOUTIQUE GYN WELLNESS CENTER
Street 2970 CLAIRMONT ROAD, NE, SUITE 903
City ATLANTA
State GA
ZIP 30329
Phone 404 344-0003
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 4/15/2025
Certificate Expiration Date 4/14/2027
Facility Type Physician Office
Lab Director FONDA D. MARTIN

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