10D1060360 CLIA NUMBER - WALLACE FAMILY PRACTICE, PA

Laboratory Demographics

  • CLIA Code: 10D1060360
  • Facility Name: WALLACE FAMILY PRACTICE, PA
  • Facility Address: 14651 PALM BEACH BLVD - #100
    FORT MYERS, FL
    ZIP 33905
  • Facility Phone: 239 369-2903
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: TASHA B. WALLACE
  • NPI Number: 1063548410
  • Taxonomy: 261Q00000X - Clinic/Center

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CLIA Record

Field Name Field Value
CLIA Number 10D1060360
LAB Type Physician Office
Facility Name WALLACE FAMILY PRACTICE, PA
Street 14651 PALM BEACH BLVD - #100
City FORT MYERS
State FL
ZIP 33905
Phone 239 369-2903
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 7/9/2024
Certificate Expiration Date 7/8/2026
Facility Type Physician Office
Lab Director TASHA B. WALLACE

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