11D2135806 CLIA NUMBER - LAKESIDE FAMILY MEDICINE

Laboratory Demographics

CLIA Number: 11D2135806

Facility Name: LAKESIDE FAMILY MEDICINE

Facility Address:
104 CARRINGTON PARK DRIVE, SUITE B
GAINESVILLE, GA
ZIP 30504
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Facility Phone Number: 470 252-5933

Facility Type: Ancillary Testing Site in Health Care Center

Certificate Type: Waiver

NPI Number: 1720514029

Taxonomy: 261QP2300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	11D2135806
LAB Type	Ancillary Testing Site in Health Care Center
Facility Name	LAKESIDE FAMILY MEDICINE
Street	104 CARRINGTON PARK DRIVE, SUITE B
City	GAINESVILLE
State	GA
ZIP	30504
Phone	470 252-5933
CertificateType	4
CertificateEffectiveDate	8/29/2023
CertificateExpirationDate	8/28/2025
FacilityType	Waiver

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