Healthcare Provider Details

I. General information

NPI: 1649089566
Provider Name (Legal Business Name): MARY LATRELLE REESE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2025
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1393 CLEVELAND AVE STE 107EAST
EAST POINT GA
30344-3423
US

IV. Provider business mailing address

290 MONTEGO CIR
RIVERDALE GA
30274-3617
US

V. Phone/Fax

Practice location:
  • Phone: 404-548-3100
  • Fax:
Mailing address:
  • Phone: 404-548-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: