Provider Demographics
NPI:1780338517
Name:HEALING HANDS DIAGNOSTIC LAB LLC
Entity type:Organization
Organization Name:HEALING HANDS DIAGNOSTIC LAB LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:STACI
Authorized Official - Middle Name:
Authorized Official - Last Name:SLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-387-9409
Mailing Address - Street 1:4440 IDLEWOOD PARK
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-6247
Mailing Address - Country:US
Mailing Address - Phone:678-387-9409
Mailing Address - Fax:470-401-2551
Practice Address - Street 1:2256 NORTHLAKE PKWY STE 110
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4012
Practice Address - Country:US
Practice Address - Phone:678-387-9409
Practice Address - Fax:470-300-7993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-10
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No291900000XLaboratoriesMilitary Clinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003187979Medicaid