10D2079699 CLIA NUMBER - CHIPOLA SURGICAL AND MEDICAL SPECIALTIES PEDIATRICS

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Laboratory Demographics

CLIA Number: 10D2079699

Facility Name: CHIPOLA SURGICAL AND MEDICAL SPECIALTIES PEDIATRICS

Facility Address:
3028 4TH STREET SUITE A & B
MARIANNA, FL
ZIP 32446
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Facility Phone Number: 850 718-2886

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1568705598

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	10D2079699
LAB Type	Physician Office
Facility Name	CHIPOLA SURGICAL AND MEDICAL SPECIALTIES PEDIATRICS
Street	3028 4TH STREET SUITE A & B
City	MARIANNA
State	FL
ZIP	32446
Phone	850 718-2886
CertificateType	4
CertificateEffectiveDate	6/20/2022
CertificateExpirationDate	6/19/2024
FacilityType	Waiver

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