Provider Demographics
NPI:1932507423
Name:MD PRECISION LAB
Entity Type:Organization
Organization Name:MD PRECISION LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:TALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-760-9360
Mailing Address - Street 1:1380 MILSTEAD AVE NE
Mailing Address - Street 2:STE J
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-3864
Mailing Address - Country:US
Mailing Address - Phone:770-760-9360
Mailing Address - Fax:
Practice Address - Street 1:1380 MILSTEAD AVE NE
Practice Address - Street 2:STE J
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3864
Practice Address - Country:US
Practice Address - Phone:770-760-9360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-15
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory