Provider Demographics
NPI:1154618221
Name:PRICE, ILAMAE
Entity type:Individual
Prefix:
First Name:ILAMAE
Middle Name:
Last Name:PRICE
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:ILA
Other - Middle Name:
Other - Last Name:CHURN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
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 1:609 MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:GA
Practice Address - Zip Code:30268-1142
Practice Address - Country:US
Practice Address - Phone:404-551-2799
Practice Address - Fax:678-834-5529
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-08
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA20215116247ZC0005X
247ZC0005X
GA291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11D2184009OtherCLIA