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General NPI Number Information
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NPI Number | 1619788411
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Entity Type | Organization
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Legal Business Name | PRO OMNIBUS DIAGNOSTIC CENTER LLC
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Dates
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Enumeration Date | 01/20/2025
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Last Update Date | 07/01/2025
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Provider Practice Location Address
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Address Line | 9442 S MAIN ST STE 116
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City | JONESBORO
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State | GA
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Zip | 30236-6073
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Country | US
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Telephone | 678-545-9195
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Fax |
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Provider Business Mailing Address
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Address Line | 9442 S MAIN ST STE 116
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City | JONESBORO
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State | GA
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Zip | 30236-6073
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Country | US
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Telephone | 678-545-9195
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Fax | 800-863-8054
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | MR. GARY A CLOWERS SR.
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Credential |
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Telephone | 678-545-9195
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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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