Provider Demographics
NPI:1144716424
Name:ADVANCED DIAGNOSTICS LABORATORY LLC
Entity type:Organization
Organization Name:ADVANCED DIAGNOSTICS LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:R
Authorized Official - Last Name:BAYLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-371-7711
Mailing Address - Street 1:950 EAGLES LANDING PKWY # 133
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7343
Mailing Address - Country:US
Mailing Address - Phone:856-320-2143
Mailing Address - Fax:856-320-2147
Practice Address - Street 1:1030 KINGS HWY N STE 304
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-1907
Practice Address - Country:US
Practice Address - Phone:856-320-2143
Practice Address - Fax:856-320-2147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-10
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0012217291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2637037Medicaid
GA003258190AMedicaid