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General NPI Number Information
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NPI Number | 1396751103
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Entity Type | Organization
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Legal Business Name | SOUTHERN CLINICAL LABORATORY INC.
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Dates
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Enumeration Date | 08/01/2006
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Last Update Date | 07/06/2011
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Provider Practice Location Address
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Address Line | 405 W PIKE ST SUIET A
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-4845
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Country | US
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Telephone | 770-513-4140
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Fax | 770-682-9529
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Provider Business Mailing Address
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Address Line | 405 W PIKE ST SUIET A
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-4845
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Country | US
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Telephone | 770-513-4140
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Fax | 770-682-9529
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. RAVINDER C REDDY
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Credential | MS
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Telephone | 770-513-4140
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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 | 067-025
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License Number State | GA
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