Healthcare Provider Details

I. General information

NPI: 1255473906
Provider Name (Legal Business Name): MACON CLINICAL LABORATORY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 NJEFFERSON STREET
MACON MS
39341
US

IV. Provider business mailing address

PO BOX 306
MACON MS
39341-0306
US

V. Phone/Fax

Practice location:
  • Phone: 662-726-5831
  • Fax: 662-726-4638
Mailing address:
  • Phone: 662-726-5831
  • Fax: 662-726-4638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateMS

VIII. Authorized Official

Name: ERNEST ROY STUART
Title or Position: ADMINISTRATOR
Credential:
Phone: 662-726-5831