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General NPI Number Information
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NPI Number | 1134870249
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Entity Type | Organization
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Legal Business Name | ON DEMAND DIAGNOSTIC LAB LLC
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Dates
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Enumeration Date | 01/11/2022
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Last Update Date | 02/25/2022
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Provider Practice Location Address
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Address Line | 3229 MERCER UNIVERSITY DR
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City | MACON
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State | GA
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Zip | 31204-5029
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Country | US
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Telephone | 404-655-2292
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Fax |
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Provider Business Mailing Address
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Address Line | 6692 DANA DR
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City | MACON
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State | GA
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Zip | 31220-5207
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Country | US
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Telephone | 404-655-2292
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SHEMICKA JOHNSON
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Credential |
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Telephone | 404-655-2292
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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