11D2057902 CLIA NUMBER - PREMISE HEALTH OF GEORGIA MEDICAL, PC

Home > CLIA Lookup > 11D2057902

Laboratory Demographics

CLIA Number: 11D2057902

Facility Name: PREMISE HEALTH OF GEORGIA MEDICAL, PC

Facility Address:
1122 WESTNORTH STREET
VIDALIA, GA
ZIP 30474
Get Directions

Facility Phone Number: 912 537-8488

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1447739545

Taxonomy: 261QP2300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	11D2057902
LAB Type	Physician Office
Facility Name	PREMISE HEALTH OF GEORGIA MEDICAL, PC
Street	1122 WESTNORTH STREET
City	VIDALIA
State	GA
ZIP	30474
Phone	912 537-8488
CertificateType	4
CertificateEffectiveDate	4/25/2023
CertificateExpirationDate	4/24/2025
FacilityType	Waiver

Download Record

Export to text format icon Download this CLIA NUMBER record in Text format: Export

Export to text format icon Download this CLIA NUMBER record in Excel (CSV) format: Export

Export to text format icon Download this CLIA NUMBER record in XML format: Export

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