Healthcare Provider Details

I. General information

NPI: 1255339107
Provider Name (Legal Business Name): LIFETEST OF GEORGIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 HAMMOND DR NE BUILDING I, STE 9120
ATLANTA GA
30328-5338
US

IV. Provider business mailing address

1140 HAMMOND DR NE BUILDING I, STE 9120
ATLANTA GA
30328-5338
US

V. Phone/Fax

Practice location:
  • Phone: 770-730-0119
  • Fax: 770-730-0114
Mailing address:
  • Phone: 770-730-0119
  • Fax: 770-730-0114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License NumberBL02-11466
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License NumberBL02-11466
License Number StateGA

VIII. Authorized Official

Name: LEE GALLAGHER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 770-730-0119