Provider Demographics
NPI:1134870249
Name:ON DEMAND DIAGNOSTIC LAB LLC
Entity type:Organization
Organization Name:ON DEMAND DIAGNOSTIC LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHEMICKA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-655-2292
Mailing Address - Street 1:6692 DANA DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31220-5207
Mailing Address - Country:US
Mailing Address - Phone:404-655-2292
Mailing Address - Fax:
Practice Address - Street 1:3229 MERCER UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-5029
Practice Address - Country:US
Practice Address - Phone:404-655-2292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-11
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center