Provider Demographics
NPI:1396751103
Name:SOUTHERN CLINICAL LABORATORY INC.
Entity type:Organization
Organization Name:SOUTHERN CLINICAL LABORATORY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RAVINDER
Authorized Official - Middle Name:C
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:770-513-4140
Mailing Address - Street 1:405 W PIKE ST
Mailing Address - Street 2:SUIET A
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4845
Mailing Address - Country:US
Mailing Address - Phone:770-513-4140
Mailing Address - Fax:770-682-9529
Practice Address - Street 1:405 W PIKE ST
Practice Address - Street 2:SUIET A
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4845
Practice Address - Country:US
Practice Address - Phone:770-513-4140
Practice Address - Fax:770-682-9529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA067-025291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000494535AMedicaid
GA000494535AMedicaid