Healthcare Provider Details

I. General information

NPI: 1669704532
Provider Name (Legal Business Name): NURSING HOME LABORATORY SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2010
Last Update Date: 02/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 NEW HOPE RD SW
ATLANTA GA
30331
US

IV. Provider business mailing address

1875 NEW HOPE RD SW
ATLANTA GA
30331
US

V. Phone/Fax

Practice location:
  • Phone: 404-552-3690
  • Fax: 404-344-6991
Mailing address:
  • Phone: 404-552-3690
  • Fax: 404-344-6991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number031032
License Number StateGA

VIII. Authorized Official

Name: VICKIE ANN JAMES
Title or Position: CEO/OWNER
Credential: M.D.
Phone: 404-552-3690