Provider Demographics
NPI:1104944123
Name:ATLANTA CLINICAL LABORATORIES INC
Entity type:Organization
Organization Name:ATLANTA CLINICAL LABORATORIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORIE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:OCTAVIUS
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-742-8205
Mailing Address - Street 1:1122 GRAY HWY STE 3
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31211-3206
Mailing Address - Country:US
Mailing Address - Phone:478-742-8205
Mailing Address - Fax:478-743-8072
Practice Address - Street 1:1122 GRAY HWY STE 3
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31211-3206
Practice Address - Country:US
Practice Address - Phone:478-742-8205
Practice Address - Fax:478-743-8072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0640536291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory