10D2177400 CLIA NUMBER - INDEPENDENT MEDICAL GROUP, LLC

Laboratory Demographics

CLIA Number: 10D2177400

Facility Name: INDEPENDENT MEDICAL GROUP, LLC

Facility Address:
3900 S FLORIDA AVE - STE 205
LAKELAND, FL
ZIP 33813
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Facility Phone Number: 954 526-4121

Facility Type: Other - COMM CLINIC FOR HIV

Certificate Type: Waiver

NPI Number: 1790457836

Taxonomy: 261QC1500X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	10D2177400
LAB Type	Other - COMM CLINIC FOR HIV
Facility Name	INDEPENDENT MEDICAL GROUP, LLC
Street	3900 S FLORIDA AVE - STE 205
City	LAKELAND
State	FL
ZIP	33813
Phone	954 526-4121
CertificateType	4
CertificateEffectiveDate	1/9/2024
CertificateExpirationDate	1/8/2026
FacilityType	Waiver

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