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General NPI Number Information
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NPI Number | 1073802153
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Entity Type | Organization
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Legal Business Name | POLARIS ALLERGY LABS, INC.
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Dates
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Enumeration Date | 03/29/2011
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Last Update Date | 08/08/2011
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Provider Practice Location Address
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Address Line | 3485 N DESERT DR BUILDING 2, SUITE 206A
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City | EAST POINT
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State | GA
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Zip | 30344-5724
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Country | US
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Telephone | 404-419-6311
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Fax | 404-419-6311
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Provider Business Mailing Address
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Address Line | 3316 S COBB DR SE STE A SUITE 215
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City | SMYRNA
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State | GA
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Zip | 30080-4107
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Country | US
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Telephone | 404-419-6311
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Fax | 404-419-6311
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | MR. R. JACKSON GARTH
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Credential | MBA, DBA
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Telephone | 404-419-6311
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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 |
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License Number State |
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