Provider Demographics
NPI:1063449437
Name:JOHN C GREENWALD
Entity Type:Organization
Organization Name:JOHN C GREENWALD
Other - Org Name:CK LABORATORIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENWALD
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:706-946-5227
Mailing Address - Street 1:51 OVERVIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-6648
Mailing Address - Country:US
Mailing Address - Phone:706-946-5227
Mailing Address - Fax:706-946-5228
Practice Address - Street 1:51 OVERVIEW DR
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-6611
Practice Address - Country:US
Practice Address - Phone:706-946-5227
Practice Address - Fax:706-946-5228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055-002291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000968459AMedicaid
GA11D1001949OtherCLIA
GA055-002OtherSTATE LAB LICENSE
GA055-002OtherSTATE LAB LICENSE