10D2115489 CLIA NUMBER - PREMISE HEALTH OF FLORIDA MEDICAL PA

Laboratory Demographics

CLIA Number: 10D2115489

Facility Name: PREMISE HEALTH OF FLORIDA MEDICAL PA

Facility Address:
5201 GATE PKWY STE 134
JACKSONVILLE, FL
ZIP 32256
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Facility Phone Number: 904 645-4060

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1780033498

Taxonomy: 261QM1300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	10D2115489
LAB Type	Physician Office
Facility Name	PREMISE HEALTH OF FLORIDA MEDICAL PA
Street	5201 GATE PKWY STE 134
City	JACKSONVILLE
State	FL
ZIP	32256
Phone	904 645-4060
CertificateType	4
CertificateEffectiveDate	7/8/2022
CertificateExpirationDate	7/7/2024
FacilityType	Waiver

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