10D2123741 CLIA NUMBER - ELLENTON FAMILY PRACTICE DIRECT

Laboratory Demographics

  • CLIA Code: 10D2123741
  • Facility Name: ELLENTON FAMILY PRACTICE DIRECT
  • Facility Address: 907 25TH DR, E
    ELLENTON, FL
    ZIP 34222
  • Facility Phone: 941 417-7386
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: RAPHAEL KULAWIK
  • NPI Number: 1124471503
  • Taxonomy: 207Q00000X - Family Medicine

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CLIA Record

Field Name Field Value
CLIA Number 10D2123741
LAB Type Physician Office
Facility Name ELLENTON FAMILY PRACTICE DIRECT
Street 907 25TH DR, E
City ELLENTON
State FL
ZIP 34222
Phone 941 417-7386
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 12/30/2024
Certificate Expiration Date 12/29/2026
Facility Type Physician Office
Lab Director RAPHAEL KULAWIK

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