=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154445898
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHEASTERN ENDOCRINE LABORATORY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2007
-----------------------------------------------------
Last Update Date | 08/03/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 JOHNSON FERRY ROAD SUITE 200
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-257-1900
-----------------------------------------------------
Fax | 404-257-0792
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 JOHNSON FERRY ROAD SUITE 200
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-257-1900
-----------------------------------------------------
Fax | 404-257-0792
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE ADMINISTRATOR
-----------------------------------------------------
Name | MR. H RON DAVIDSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-459-3473
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 060171
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------