10D1090544 CLIA NUMBER - JACKSONVILLE SOUTH DIALYSIS CENTER UNIT 114

Laboratory Demographics

CLIA Number: 10D1090544

Facility Name: JACKSONVILLE SOUTH DIALYSIS CENTER UNIT 114

Facility Address:
14965 OLD ST AUGUSTINE RD
JACKSONVILLE, FL
ZIP 32258
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Facility Phone Number: 904 880-9494

Facility Type: End Stage Renal Disease Dialysis Facility

Certificate Type: Waiver

NPI Number: 1255587531

Taxonomy: 261QE0700X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	10D1090544
LAB Type	End Stage Renal Disease Dialysis Facility
Facility Name	JACKSONVILLE SOUTH DIALYSIS CENTER UNIT 114
Street	14965 OLD ST AUGUSTINE RD
City	JACKSONVILLE
State	FL
ZIP	32258
Phone	904 880-9494
CertificateType	4
CertificateEffectiveDate	10/14/2022
CertificateExpirationDate	10/13/2024
FacilityType	Waiver

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