Provider Demographics
NPI:1932353042
Name:PAPP CLINIC LABORATORY
Entity Type:Organization
Organization Name:PAPP CLINIC LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:B
Authorized Official - Last Name:PERUSKI
Authorized Official - Suffix:
Authorized Official - Credentials:CPCS
Authorized Official - Phone:770-301-0231
Mailing Address - Street 1:15 CAVENDER ST
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-1931
Mailing Address - Country:US
Mailing Address - Phone:770-253-6616
Mailing Address - Fax:
Practice Address - Street 1:15 CAVENDER ST
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-1931
Practice Address - Country:US
Practice Address - Phone:770-253-6616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PAPP CLINIC, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-17
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038-005291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA038-005OtherDEPT OF HUMAN RESOURCES CLINICAL LAB LICENSE
GA11D0257911OtherCLIA CERTIFICATION NUMBER