Organization
GEORGIA LITHOTRIPSY AND LASER CENTER
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DAVID C ALLEN (PRESIDENT)
(706) 543-2718
Entity
Organization
Contact information
Practice address
120 TRINITY PL, ATHENS, GA 30607-2100
(706) 543-2718
(706) 353-3709
Mailing address
120 TRINITY PL, ATHENS, GA 30607-2100
(706) 543-2718
(706) 353-3709
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
—
—
261QL0400X
Lithotripsy Clinic/Center
029-044
GA
261QR0200X
Radiology Clinic/Center
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00451316A
—
GA
01
—
581596177001
CHAMPUS
GA
01
—
590
BLUE CROSS BLUE SHIELD
GA
Enumeration date
10/04/2006
Last updated
11/05/2008
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