05D1013565 CLIA NUMBER - FAMILY PRACTICE HEALTH AND WELLNESS MEDICAL GROUP

Laboratory Demographics

CLIA Number: 05D1013565

Facility Name: FAMILY PRACTICE HEALTH AND WELLNESS MEDICAL GROUP

Facility Address:
2020 STANDIFORD AVENUE, SUITE D3
MODESTO, CA
ZIP 95350
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Facility Phone Number: 209 575-4990

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1164754347

Taxonomy: 332900000X - Non-Pharmacy Dispensing Site
A site other than a pharmacy that dispenses medicinal preparations under the supervision of a physician to patients for self-administration. (e.g. physician offices, ER, Urgent Care Centers, Rural Health Facilities, etc.)

CLIA Record

Field Name	Field Value
CLIA Number	05D1013565
LAB Type	Physician Office
Facility Name	FAMILY PRACTICE HEALTH AND WELLNESS MEDICAL GROUP
Street	2020 STANDIFORD AVENUE, SUITE D3
City	MODESTO
State	CA
ZIP	95350
Phone	209 575-4990
CertificateType	4
CertificateEffectiveDate	2/6/2024
CertificateExpirationDate	2/5/2026
FacilityType	Waiver

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