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General NPI Number Information
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NPI Number | 1063449437
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Entity Type | Organization
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Legal Business Name | JOHN C GREENWALD
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Dates
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Enumeration Date | 06/28/2006
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Last Update Date | 06/08/2017
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Provider Practice Location Address
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Address Line | 51 OVERVIEW DR
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City | BLUE RIDGE
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State | GA
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Zip | 30513-6611
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Country | US
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Telephone | 706-946-5227
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Fax | 706-946-5228
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Provider Business Mailing Address
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Address Line | 51 OVERVIEW DRIVE
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City | BLUE RIDGE
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State | GA
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Zip | 30513-6648
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Country | US
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Telephone | 706-946-5227
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Fax | 706-946-5228
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Authorized Official
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Title or Position | OWNER
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Name | MR. JOHN GREENWALD
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Credential | MT
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Telephone | 706-946-5227
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 055-002
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License Number State | GA
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