09D2240399 CLIA NUMBER - DERVAN HEALTHCARE SERVICES LLC

Laboratory Demographics

CLIA Number: 09D2240399

Facility Name: DERVAN HEALTHCARE SERVICES LLC

Facility Address:
3849 PENNSLYVANIA AVENUE SE
WASHINGTON, DC
ZIP 20020
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Facility Phone Number: 202 629-6975

Facility Type: Other - PRIMARY CARE

Certificate Type: Waiver

NPI Number: 1275182560

Taxonomy: 261QP2300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	09D2240399
LAB Type	Other - PRIMARY CARE
Facility Name	DERVAN HEALTHCARE SERVICES LLC
Street	3849 PENNSLYVANIA AVENUE SE
City	WASHINGTON
State	DC
ZIP	20020
Phone	202 629-6975
CertificateType	4
CertificateEffectiveDate	10/19/2023
CertificateExpirationDate	10/18/2025
FacilityType	Waiver

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