Provider Demographics
NPI:1063698595
Name:HARBIN CLINIC, LLC
Entity type:Organization
Organization Name:HARBIN CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:F
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:762-235-1000
Mailing Address - Street 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:1825 MARTHA BERRY BLVD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1625
Practice Address - Country:US
Practice Address - Phone:706-295-5331
Practice Address - Fax:706-236-6423
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HARBIN CLINIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-15
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057-007291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000315609AMedicaid
GAX10232Medicare UPIN