Healthcare Provider Details

I. General information

NPI: 1386739498
Provider Name (Legal Business Name): GEORGIA LITHOTRIPSY AND LASER CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 11/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 TRINITY PL
ATHENS GA
30607-2100
US

IV. Provider business mailing address

120 TRINITY PL
ATHENS GA
30607-2100
US

V. Phone/Fax

Practice location:
  • Phone: 706-543-2718
  • Fax: 706-353-3709
Mailing address:
  • Phone: 706-543-2718
  • Fax: 706-353-3709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QL0400X
TaxonomyLithotripsy Clinic/Center
License Number029-044
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DAVID C ALLEN
Title or Position: PRESIDENT
Credential:
Phone: 706-543-2718