Provider Demographics
NPI:1972112795
Name:COVID COMMUNITY TESTING LLC
Entity type:Organization
Organization Name:COVID COMMUNITY TESTING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:W
Authorized Official - Last Name:WALRAVEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-364-8414
Mailing Address - Street 1:1000 COMMERCE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-3520
Mailing Address - Country:US
Mailing Address - Phone:678-364-8404
Mailing Address - Fax:678-545-0146
Practice Address - Street 1:1000 COMMERCE DR STE 400
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-3520
Practice Address - Country:US
Practice Address - Phone:678-364-8404
Practice Address - Fax:678-545-0146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-28
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4026OtherMEDICARE - GA