04D2113561 CLIA NUMBER - WAGNER MEDICAL CLINIC

Laboratory Demographics

  • CLIA Code: 04D2113561
  • Facility Name: WAGNER MEDICAL CLINIC
  • Facility Address: 1001 N 6TH STREET
    BLYTHEVILLE, AR
    ZIP 72315
  • Facility Phone: 870 561-3300
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: DR. TOMMY W. WAGNER
  • NPI Number: 1316041957
  • Taxonomy: 261QR1300X - Clinic/Center

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CLIA Record

Field Name Field Value
CLIA Number 04D2113561
LAB Type Physician Office
Facility Name WAGNER MEDICAL CLINIC
Street 1001 N 6TH STREET
City BLYTHEVILLE
State AR
ZIP 72315
Phone 870 561-3300
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 5/25/2024
Certificate Expiration Date 5/24/2026
Facility Type Physician Office
Lab Director DR. TOMMY W. WAGNER

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