Provider Demographics
NPI:1659726487
Name:PURE DIAGNOSTIC, LLC
Entity Type:Organization
Organization Name:PURE DIAGNOSTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CLAIR
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-456-9928
Mailing Address - Street 1:4025 PLEASANTDALE RD STE 525
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30340-4265
Mailing Address - Country:US
Mailing Address - Phone:423-713-7481
Mailing Address - Fax:423-713-7483
Practice Address - Street 1:4025 PLEASANTDALE RD STE 525
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30340-4265
Practice Address - Country:US
Practice Address - Phone:423-713-7481
Practice Address - Fax:423-713-7483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-29
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA44D2111056OtherCLIA