MEDICARE: ANTONIO PADILLA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory		GA

General Provider Information

NPI Number	:	1427279538
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANTONIO PADILLA

Provider Business Mailing Address
First Line	:	2195 INGLESIDE AVE
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31204-2029
Country	:	US
Telephone Number	:	877-307-6654
Fax Number	:

Provider Business Practice Location Address
First Line	:	2195 INGLESIDE AVE
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31204-2029
Country	:	US
Telephone Number	:	877-307-6654
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ANTONIO PADILLA
Credential	:
Telephone Number	:	18773076654

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	08/22/2020

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