Provider Demographics
NPI:1871190686
Name:ALLEGIANT SOLUTIONS LLC
Entity type:Organization
Organization Name:ALLEGIANT SOLUTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-460-8671
Mailing Address - Street 1:5101 NORTHWIND BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-7774
Mailing Address - Country:US
Mailing Address - Phone:229-262-7242
Mailing Address - Fax:229-262-7248
Practice Address - Street 1:5101 NORTHWIND BLVD STE B
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-7774
Practice Address - Country:US
Practice Address - Phone:229-262-7242
Practice Address - Fax:229-262-7248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-05
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003245188AMedicaid