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NPI Code Detail

MEDICARE: ALPHONSUS MADUWUBA AGBAERE MT(ASCP)CLS(NCA)

MEDICARE: ALPHONSUS MADUWUBA AGBAERE MT(ASCP)CLS(NCA)
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
1246RM2200XMedical Laboratory Technician163311GA
2247ZC0005XClinical Laboratory Director (Non-physician)163311GA

General Provider Information

NPI Number : 1760626279
Entity Type Code : Individual
Provider Name (Legal Business Name) : ALPHONSUS MADUWUBA AGBAERE MT(ASCP)CLS(NCA)
Provider Business Mailing Address
First Line : 2222 COLUMBIA DR
Second Line :
City : DECATUR
State : GA
Zip : 30032-7206
Country : US
Telephone Number : 404-286-2838
Fax Number :
Provider Business Practice Location Address
First Line : 1670 CLAIRMONT RD
Second Line :
City : DECATUR
State : GA
Zip : 30033-4004
Country : US
Telephone Number : 404-321-6111
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/28/2009
Last Update Date : 04/28/2009

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Directions to “ ALPHONSUS MADUWUBA AGBAERE MT(ASCP)CLS(NCA)” Practice Location

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