=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598427734
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | APOLLO MEDCO, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2021
-----------------------------------------------------
Last Update Date | 10/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3365 PIEDMONT RD NE STE 1400
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30305-1795
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-574-5870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7295 LAUREL OAK DR
-----------------------------------------------------
City | SUWANEE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30024-5366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-281-7753
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. KENNETH DUNWODY III
-----------------------------------------------------
Credential | CLIA LAB DIRECTOR
-----------------------------------------------------
Telephone | 404-281-7753
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------