Provider Demographics
NPI:1962503037
Name:PERNICIARO LABORATORIES OF GEORGIA PC
Entity Type:Organization
Organization Name:PERNICIARO LABORATORIES OF GEORGIA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:V
Authorized Official - Last Name:PERNICIARO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-265-2142
Mailing Address - Street 1:3008 E PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4241
Mailing Address - Country:US
Mailing Address - Phone:912-265-2142
Mailing Address - Fax:912-265-0530
Practice Address - Street 1:3008 E PARK AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4241
Practice Address - Country:US
Practice Address - Phone:912-265-2142
Practice Address - Fax:912-265-0530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory