Provider Demographics
NPI:1760579825
Name:CLINICAL LABORATORY SERVICES, INC.
Entity Type:Organization
Organization Name:CLINICAL LABORATORY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:SILMARY
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ-CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-307-5820
Mailing Address - Street 1:189 W ATHENS ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WINDER
Mailing Address - State:GA
Mailing Address - Zip Code:30680-2295
Mailing Address - Country:US
Mailing Address - Phone:770-307-5820
Mailing Address - Fax:678-963-9946
Practice Address - Street 1:189 W ATHENS ST
Practice Address - Street 2:SUITE 2
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-2295
Practice Address - Country:US
Practice Address - Phone:770-307-5820
Practice Address - Fax:678-963-9946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007003291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00762539AMedicaid
GAN317983OtherWELLCARE
GA10037329OtherAMERIGROUP
GA115684OtherPEACH STATE HEALTH PLAN
GA3500072OtherEVERCARE
GA690007903OtherRAILROAD MEDICARE
GA3500072OtherEVERCARE