04D2015798 CLIA NUMBER - RIVERSIDE MEDICAL CLINIC

Laboratory Demographics

  • CLIA Code: 04D2015798
  • Facility Name: RIVERSIDE MEDICAL CLINIC
  • Facility Address: 803 HWY 18
    LAKE CITY, AR
    ZIP 72437
  • Facility Phone: 870 237-1055
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: DR. TOMMY W. WAGNER
  • NPI Number: 1811206923
  • Taxonomy: 207Q00000X - Family Medicine

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CLIA Record

Field Name Field Value
CLIA Number 04D2015798
LAB Type Physician Office
Facility Name RIVERSIDE MEDICAL CLINIC
Street 803 HWY 18
City LAKE CITY
State AR
ZIP 72437
Phone 870 237-1055
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 11/4/2024
Certificate Expiration Date 11/3/2026
Facility Type Physician Office
Lab Director DR. TOMMY W. WAGNER

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This page was last updated on: 9/29/2025