Basic Information
| Provider Information | |||||||||
| NPI: | 1467016055 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HARBIN CLINIC, LLC | ||||||||
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| OtherOrganizationName: | HARBIN CLINIC GI LAB CARTERSVILLE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 TECHNOLOGY PKWY NW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301651369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7622351000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 GENTILLY BLVD | ||||||||
| Address2: | |||||||||
| City: | CARTERSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4704906460 | ||||||||
| FaxNumber: | 6787214386 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2019 | ||||||||
| LastUpdateDate: | 11/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | DIEHL | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7622351166 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HARBIN CLINIC, LLC | ||||||||
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| NPICertificationDate: | 11/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 003239105A | 05 | GA | MEDICAID |