Provider Demographics
NPI:1609269018
Name:GEORGIA STATE DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:GEORGIA STATE DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-474-9253
Mailing Address - Street 1:3379 PEACHTREE RD NE
Mailing Address - Street 2:SUITE 555
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30326-1031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3379 PEACHTREE RD NE
Practice Address - Street 2:SUITE 555
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30326-1031
Practice Address - Country:US
Practice Address - Phone:407-474-9253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NATIONAL DIAGNOSTIC SOLUTIONS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center