=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528436367
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BIOCONFIRM LABORATORIES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2015
-----------------------------------------------------
Last Update Date | 04/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6755 PEACHTREE INDUSTRIAL BLVD SUITE 150
-----------------------------------------------------
City | DORAVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-449-4193
-----------------------------------------------------
Fax | 770-559-4378
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6755 PEACHTREE INDUSTRIAL BLVD
-----------------------------------------------------
City | DORAVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30360-2223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-449-4193
-----------------------------------------------------
Fax | 770-559-4378
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PAST CREDENTIALING AGENT/AO
-----------------------------------------------------
Name | PAULA DEANNE CROOK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-449-4193
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------