MEDICARE: REVEAL DIAGNOSTIC SERVICES, 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	:	1285278846
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVEAL DIAGNOSTIC SERVICES, INC

Provider Business Mailing Address
First Line	:	3915 CASCADE RD SW STE 355
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-8520
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3915 CASCADE RD SW STE 355
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-8520
Country	:	US
Telephone Number	:	404-549-9680
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CAROLYN WELLER
Credential	:
Telephone Number	:	404-549-9680

Provider Enumeration Date	:	11/06/2019
Last Update Date	:	03/05/2024

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