10D2004282 CLIA NUMBER - PONTE VEDRA AMBULATORY SURGERY CENTER PONTE VEDRA PLASTIC SURGERY

Laboratory Demographics

  • CLIA Code: 10D2004282
  • Facility Name: PONTE VEDRA AMBULATORY SURGERY CENTER PONTE VEDRA PLASTIC SURGERY
  • Facility Address: 209 PONTE VEDRA PARK DR
    PONTE VEDRA BEACH, FL
    ZIP 32082
  • Facility Phone: 907 273-6200
  • Facility Type: Ambulatory Surgery Center
  • Facility Type: Waiver
  • Lab Director: HOLLIE JO HICKMAN
  • NPI Number: 1346260155
  • Taxonomy: 122300000X - Dentist

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CLIA Record

Field Name Field Value
CLIA Number 10D2004282
LAB Type Ambulatory Surgery Center
Facility Name PONTE VEDRA AMBULATORY SURGERY CENTER PONTE VEDRA PLASTIC SURGERY
Street 209 PONTE VEDRA PARK DR
City PONTE VEDRA BEACH
State FL
ZIP 32082
Phone 907 273-6200
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 3/2/2024
Certificate Expiration Date 3/1/2026
Facility Type Ambulatory Surgery Center
Lab Director HOLLIE JO HICKMAN

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