MEDICARE: EXCEL DIAGNOSTIC LABORATORY, 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	033-109	GA

General Provider Information

NPI Number	:	1326594722
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXCEL DIAGNOSTIC LABORATORY, INC.

Provider Business Mailing Address
First Line	:	2740 JEFFERSON ST
Second Line	:	SUITE B
City	:	AUSTELL
State	:	GA
Zip	:	30168-4014
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2740 JEFFERSON ST
Second Line	:	SUITE B
City	:	AUSTELL
State	:	GA
Zip	:	30168-4014
Country	:	US
Telephone Number	:	404-219-0912
Fax Number	:

Authorized Official
Title or Position	:	TECHNICAL DIRECTOR
Name	:	MR. EUGENE H. RUSSELL III
Credential	:
Telephone Number	:	404-219-0912

Provider Enumeration Date	:	08/26/2016
Last Update Date	:	08/26/2016

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