Healthcare Provider Details

I. General information

NPI: 1154618221
Provider Name (Legal Business Name): ILAMAE PRICE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. ILA CHURN

II. Dates (important events)

Enumeration Date: 07/08/2011
Last Update Date: 08/23/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 MAIN ST STE B
PALMETTO GA
30268-1142
US

IV. Provider business mailing address

612 MAIN ST STE 102
PALMETTO GA
30268-1149
US

V. Phone/Fax

Practice location:
  • Phone: 404-551-2799
  • Fax: 678-834-5529
Mailing address:
  • Phone: 404-551-2799
  • Fax: 678-834-5529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number20215116
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: