MEDICARE: LIFETEST OF GEORGIA, LLC

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	261QR0200X	Radiology Clinic/Center	BL02-11466	GA
2	261QR0206X	Mammography Clinic/Center	BL02-11466	GA

General Provider Information

NPI Number	:	1255339107
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFETEST OF GEORGIA, LLC

Provider Business Mailing Address
First Line	:	1140 HAMMOND DR NE
Second Line	:	BUILDING I, STE 9120
City	:	ATLANTA
State	:	GA
Zip	:	30328-5338
Country	:	US
Telephone Number	:	770-730-0119
Fax Number	:	770-730-0114

Provider Business Practice Location Address
First Line	:	1140 HAMMOND DR NE
Second Line	:	BUILDING I, STE 9120
City	:	ATLANTA
State	:	GA
Zip	:	30328-5338
Country	:	US
Telephone Number	:	770-730-0119
Fax Number	:	770-730-0114

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	LEE GALLAGHER
Credential	:
Telephone Number	:	770-730-0119

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	09/11/2025

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