01D2152025 CLIA NUMBER - LAKESIDE PRIMARY CARE

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Laboratory Demographics

CLIA Number: 01D2152025

Facility Name: LAKESIDE PRIMARY CARE

Facility Address:
1260 CHESNUT BYPASS, SUITE A
CENTRE, AL
ZIP 35960
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Facility Phone Number: 256 266-1544

Facility Type: Practitioner Other

Certificate Type: Waiver

NPI Number: 1720572407

Taxonomy: 363LP2300X - Nurse Practitioner

CLIA Record

Field Name	Field Value
CLIA Number	01D2152025
LAB Type	Practitioner Other
Facility Name	LAKESIDE PRIMARY CARE
Street	1260 CHESNUT BYPASS, SUITE A
City	CENTRE
State	AL
ZIP	35960
Phone	256 266-1544
CertificateType	4
CertificateEffectiveDate	8/1/2022
CertificateExpirationDate	7/31/2024
FacilityType	Waiver

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This page was last updated on: 4/23/2024