Provider Demographics
NPI:1629822259
Name:ETHEREAL DIAGNOSTICS & SERVICES LLC
Entity Type:Organization
Organization Name:ETHEREAL DIAGNOSTICS & SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PORSHA
Authorized Official - Middle Name:TERELL
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:877-586-2971
Mailing Address - Street 1:1 GRAND PARK LN APT 3119
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31757-4909
Mailing Address - Country:US
Mailing Address - Phone:229-579-6847
Mailing Address - Fax:
Practice Address - Street 1:100 N PATTERSON ST STE A
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-5570
Practice Address - Country:US
Practice Address - Phone:877-586-2971
Practice Address - Fax:866-703-1440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service