Provider Demographics
NPI:1780354183
Name:LABORATORY DOCTORS NETWORK LLC
Entity type:Organization
Organization Name:LABORATORY DOCTORS NETWORK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF LABORATORY SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:ILA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:404-551-2799
Mailing Address - Street 1:612 MAIN ST STE 102
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:GA
Mailing Address - Zip Code:30268-1149
Mailing Address - Country:US
Mailing Address - Phone:404-551-2799
Mailing Address - Fax:678-834-5529
Practice Address - Street 1:612 MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:GA
Practice Address - Zip Code:30268-1149
Practice Address - Country:US
Practice Address - Phone:404-551-2799
Practice Address - Fax:678-834-5529
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ILAMAE PRICE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-09-16
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11D2184009OtherCMS CLIA CERTIFICATE OF WAIVER