Provider Demographics
NPI:1457091761
Name:PCL LABS LLC
Entity Type:Organization
Organization Name:PCL LABS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAWIT
Authorized Official - Middle Name:
Authorized Official - Last Name:MENGESHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-418-4458
Mailing Address - Street 1:4600 E PONCE DE LEON AVE STE B
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30021-1839
Mailing Address - Country:US
Mailing Address - Phone:470-418-4458
Mailing Address - Fax:303-653-6412
Practice Address - Street 1:4600 E PONCE DE LEON AVE STE B
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:GA
Practice Address - Zip Code:30021-1839
Practice Address - Country:US
Practice Address - Phone:470-418-4458
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-01
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory