Healthcare Provider Details

I. General information

NPI: 1992819072
Provider Name (Legal Business Name): TRANS ALLIANCE LAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3050 MARTIN LUTHER KING JR DR SW STE H
ATLANTA GA
30311-1500
US

IV. Provider business mailing address

PO BOX 767757
ROSWELL GA
30076-7757
US

V. Phone/Fax

Practice location:
  • Phone: 404-699-9000
  • Fax: 404-699-9111
Mailing address:
  • Phone: 404-699-9000
  • Fax: 404-699-9111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberPHRE008987
License Number StateGA

VIII. Authorized Official

Name: CHINWE BIBI NWABUDE
Title or Position: PHARMACIST
Credential:
Phone: 404-699-9000