Provider Demographics
NPI:1629677034
Name:MOORE DIAGNOSTIC LABORATORY, INC.
Entity Type:Organization
Organization Name:MOORE DIAGNOSTIC LABORATORY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:JUNE
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:678-920-0058
Mailing Address - Street 1:5590 MABLETON PKWY SW STE 174
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-3303
Mailing Address - Country:US
Mailing Address - Phone:678-920-0058
Mailing Address - Fax:
Practice Address - Street 1:5590 MABLETON PKWY SW STE 174
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-3303
Practice Address - Country:US
Practice Address - Phone:678-920-0058
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-19
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty