04D2143000 CLIA NUMBER - AIR EVAC LIFETEAM 149

Laboratory Demographics

  • CLIA Code: 04D2143000
  • Facility Name: AIR EVAC LIFETEAM 149
  • Facility Address: 1321 DODSON AVE
    FORT SMITH, AR
    ZIP 72901
  • Facility Phone: 479 387-0806
  • Facility Type: Mobile Laboratory
  • Facility Type: Waiver
  • Lab Director: DAISY FULTZ
  • NPI Number: 1679085989
  • Taxonomy: 3416A0800X - Ambulance

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CLIA Record

Field Name Field Value
CLIA Number 04D2143000
LAB Type Mobile Laboratory
Facility Name AIR EVAC LIFETEAM 149
Street 1321 DODSON AVE
City FORT SMITH
State AR
ZIP 72901
Phone 479 387-0806
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 1/23/2024
Certificate Expiration Date 1/22/2026
Facility Type Mobile Laboratory
Lab Director DAISY FULTZ

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