=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326594722
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXCEL DIAGNOSTIC LABORATORY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2016
-----------------------------------------------------
Last Update Date | 08/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2740 JEFFERSON ST SUITE B
-----------------------------------------------------
City | AUSTELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30168-4014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-219-0912
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2740 JEFFERSON ST SUITE B
-----------------------------------------------------
City | AUSTELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30168-4014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | TECHNICAL DIRECTOR
-----------------------------------------------------
Name | MR. EUGENE H. RUSSELL III
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-219-0912
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 033-109
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------