Provider Demographics
NPI:1467016055
Name:HARBIN CLINIC, LLC
Entity Type:Organization
Organization Name:HARBIN CLINIC, LLC
Other - Org Name:HARBIN CLINIC GI LAB CARTERSVILLE
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DIEHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:762-235-1166
Mailing Address - Street 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:200 GENTILLY BLVD
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120
Practice Address - Country:US
Practice Address - Phone:470-490-6460
Practice Address - Fax:678-721-4386
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HARBIN CLINIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-04-29
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003239105AMedicaid