Provider Demographics
NPI:1528125648
Name:INFINITY LABORATORY
Entity type:Organization
Organization Name:INFINITY LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ODILEE
Authorized Official - Middle Name:E
Authorized Official - Last Name:KELSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-750-7732
Mailing Address - Street 1:841 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31206
Mailing Address - Country:US
Mailing Address - Phone:478-750-7732
Mailing Address - Fax:478-750-7736
Practice Address - Street 1:841 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-6756
Practice Address - Country:US
Practice Address - Phone:478-750-7732
Practice Address - Fax:478-750-7736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011-023291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA69WBDLRMedicare ID - Type Unspecified