Provider Demographics
NPI:1255339107
Name:LIFETEST OF GEORGIA, LLC
Entity type:Organization
Organization Name:LIFETEST OF GEORGIA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLAGHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-730-0119
Mailing Address - Street 1:1140 HAMMOND DR NE
Mailing Address - Street 2:BUILDING I, STE 9120
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5338
Mailing Address - Country:US
Mailing Address - Phone:770-730-0119
Mailing Address - Fax:770-730-0114
Practice Address - Street 1:1140 HAMMOND DR NE
Practice Address - Street 2:BUILDING I, STE 9120
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-5338
Practice Address - Country:US
Practice Address - Phone:770-730-0119
Practice Address - Fax:770-730-0114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GABL02-11466261QR0200X, 261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Not Answered261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography