MEDICARE: POLARIS ALLERGY LABS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1073802153
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POLARIS ALLERGY LABS, INC.

Provider Business Mailing Address
First Line	:	3316 S COBB DR SE STE A
Second Line	:	SUITE 215
City	:	SMYRNA
State	:	GA
Zip	:	30080-4107
Country	:	US
Telephone Number	:	404-419-6311
Fax Number	:	404-419-6311

Provider Business Practice Location Address
First Line	:	3485 N DESERT DR
Second Line	:	BUILDING 2, SUITE 206A
City	:	EAST POINT
State	:	GA
Zip	:	30344-5724
Country	:	US
Telephone Number	:	404-419-6311
Fax Number	:	404-419-6311

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MR. R. JACKSON GARTH
Credential	:	MBA, DBA
Telephone Number	:	404-419-6311

Provider Enumeration Date	:	03/29/2011
Last Update Date	:	08/08/2011

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