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General NPI Number Information
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NPI Number | 1942234141
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Entity Type | Organization
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Legal Business Name | VIDALIA LAB SERVICES, INC
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Dates
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Enumeration Date | 07/11/2006
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Last Update Date | 04/08/2010
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Provider Practice Location Address
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Address Line | 801 MCNATT ST
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City | VIDALIA
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State | GA
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Zip | 30474-8808
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Country | US
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Telephone | 912-537-0622
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Fax | 912-537-0641
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Provider Business Mailing Address
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Address Line | 801 MCNATT ST
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City | VIDALIA
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State | GA
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Zip | 30474-8808
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Country | US
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Telephone | 912-537-0622
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Fax | 912-537-0641
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Authorized Official
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Title or Position | PRESIDENT
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Name | RILEY MCDONALD
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Credential |
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Telephone | 912-537-0622
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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 | 06012R
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License Number State | GA
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