Healthcare Provider Details

I. General information

NPI: 1134619653
Provider Name (Legal Business Name): ANDREW WILLIAM BERNAL MLT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2018
Last Update Date: 05/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 CLAIRMONT RD
DECATUR GA
30033-4032
US

IV. Provider business mailing address

1123 SABLE XING
SUWANEE GA
30024-3867
US

V. Phone/Fax

Practice location:
  • Phone: 240-723-5779
  • Fax:
Mailing address:
  • Phone: 240-723-5779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number84666
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: