Provider Demographics
NPI:1154209666
Name:MEDPRO CLINICAL & ADMINISTRATIVE SERVICES OF ATLANTA
Entity type:Organization
Organization Name:MEDPRO CLINICAL & ADMINISTRATIVE SERVICES OF ATLANTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LATOYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:PA-S, CCMA CPT
Authorized Official - Phone:770-402-8116
Mailing Address - Street 1:1004 TAYLOR CT
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-7592
Mailing Address - Country:US
Mailing Address - Phone:770-402-8116
Mailing Address - Fax:404-566-7923
Practice Address - Street 1:1004 TAYLOR CT
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30102-7592
Practice Address - Country:US
Practice Address - Phone:770-402-8116
Practice Address - Fax:404-566-7923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-22
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physicianGroup - Multi-Specialty