Healthcare Provider Details

I. General information

NPI: 1568302784
Provider Name (Legal Business Name): NEXTGEN DIAGNOSTIC LAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 N CHARLES ST FL 9
BALTIMORE MD
21201-3758
US

IV. Provider business mailing address

295 LIMESTONE CIR
CONYERS GA
30013-5244
US

V. Phone/Fax

Practice location:
  • Phone: 443-781-1216
  • Fax:
Mailing address:
  • Phone: 443-781-1216
  • Fax: 443-781-1216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: VEGAS LAHAIE
Title or Position: CEO
Credential:
Phone: 443-781-1216