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General NPI Number Information
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NPI Number | 1417330465
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Entity Type | Organization
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Legal Business Name | EGL GENETIC DIAGNOSTICS, LLC
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Dates
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Enumeration Date | 07/08/2015
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Last Update Date | 10/15/2020
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Provider Practice Location Address
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Address Line | 2460 MOUNTAIN INDUSTRIAL BLVD
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City | TUCKER
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State | GA
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Zip | 30084-3812
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Country | US
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Telephone | 470-378-2200
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Fax | 470-378-2250
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Provider Business Mailing Address
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Address Line | 2460 MOUNTAIN INDUSTRIAL BLVD
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City | TUCKER
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State | GA
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Zip | 30084-3812
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Country | US
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Telephone | 816-251-0440
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Fax | 816-347-0143
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Authorized Official
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Title or Position | DIRECTOR
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Name | MATTHEW GARY URBANEK
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Credential |
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Telephone | 816-554-5111
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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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