Provider Demographics
NPI:1770987364
Name:REGIONAL LAB OUTREACH
Entity type:Organization
Organization Name:REGIONAL LAB OUTREACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT AND CFO
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-475-3463
Mailing Address - Street 1:1199 PRINCE AVENUE
Mailing Address - Street 2:REGIONAL LAB OUTREACH
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606
Mailing Address - Country:US
Mailing Address - Phone:706-475-3318
Mailing Address - Fax:706-475-5349
Practice Address - Street 1:1199 PRINCE AVE
Practice Address - Street 2:REGIONAL LAB OUTREACH
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2797
Practice Address - Country:US
Practice Address - Phone:706-475-3318
Practice Address - Fax:706-475-5349
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PIEDMONT ATHENS REGIONAL MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-10
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029-007282N00000X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00000074AMedicaid
GA00000074AMedicaid