Provider Demographics
NPI:1124409958
Name:CHATTAHOOCHEE PHYSICIANS LABORATORY SERVICES, LLC
Entity Type:Organization
Organization Name:CHATTAHOOCHEE PHYSICIANS LABORATORY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LAB ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-674-4468
Mailing Address - Street 1:1122 CAMBRIDGE SQ
Mailing Address - Street 2:STE E
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-1858
Mailing Address - Country:US
Mailing Address - Phone:770-674-4468
Mailing Address - Fax:
Practice Address - Street 1:1122 CAMBRIDGE SQ
Practice Address - Street 2:STE E
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-1858
Practice Address - Country:US
Practice Address - Phone:770-674-4468
Practice Address - Fax:770-209-2366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-17
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1124409958Medicaid
GA003184390AMedicaid
GA11D2102909Medicare Oscar/Certification
ID1124409958Medicaid