Provider Demographics
NPI:1942234141
Name:VIDALIA LAB SERVICES, INC
Entity Type:Organization
Organization Name:VIDALIA LAB SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RILEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-537-0622
Mailing Address - Street 1:801 MCNATT ST
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8808
Mailing Address - Country:US
Mailing Address - Phone:912-537-0622
Mailing Address - Fax:912-537-0641
Practice Address - Street 1:801 MCNATT ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8808
Practice Address - Country:US
Practice Address - Phone:912-537-0622
Practice Address - Fax:912-537-0641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA06012R291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA604767895AMedicaid
GAP00317736OtherRAILROAD MEDICARE
GA604767895AMedicaid