Provider Demographics
NPI:1710284435
Name:GATES RAPID DIAGNOSTIC LABORATORY OF ATLANTA
Entity Type:Organization
Organization Name:GATES RAPID DIAGNOSTIC LABORATORY OF ATLANTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACKSON
Authorized Official - Middle Name:L
Authorized Official - Last Name:GATES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-591-6509
Mailing Address - Street 1:1880 LANCASTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013
Mailing Address - Country:US
Mailing Address - Phone:678-591-6509
Mailing Address - Fax:
Practice Address - Street 1:777 CLEVELAND AVE SW
Practice Address - Street 2:SUITE 100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-7129
Practice Address - Country:US
Practice Address - Phone:404-763-0093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-15
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038767208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty