10D2172032 CLIA NUMBER - INDEPENDENT MEDICAL GROUP, LLC

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Laboratory Demographics

CLIA Number: 10D2172032

Facility Name: INDEPENDENT MEDICAL GROUP, LLC

Facility Address:
130 E MARKS ST
ORLANDO, FL
ZIP 32803
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Facility Phone Number: 954 526-4121

Facility Type: Other - COMMUNITY CLINIC FOR HIV/

Certificate Type: Waiver

NPI Number: 1619568862

Taxonomy: 261QH0100X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	10D2172032
LAB Type	Other - COMMUNITY CLINIC FOR HIV/
Facility Name	INDEPENDENT MEDICAL GROUP, LLC
Street	130 E MARKS ST
City	ORLANDO
State	FL
ZIP	32803
Phone	954 526-4121
CertificateType	4
CertificateEffectiveDate	9/13/2023
CertificateExpirationDate	9/12/2025
FacilityType	Waiver

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