Provider Demographics
NPI:1750636676
Name:GENOVA DIAGNOSTICS INC
Entity Type:Organization
Organization Name:GENOVA DIAGNOSTICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:LEDFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-210-7764
Mailing Address - Street 1:3425 CORPORATE WAY
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-2552
Mailing Address - Country:US
Mailing Address - Phone:678-638-2918
Mailing Address - Fax:678-638-2919
Practice Address - Street 1:3425 CORPORATE WAY
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-2552
Practice Address - Country:US
Practice Address - Phone:678-638-2918
Practice Address - Fax:678-638-2919
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENOVA DIAGNOSTICS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-07-17
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11D0255349291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory