11D2259716 CLIA NUMBER - VIDALIA IMMEDIATE AND PRIMARY CARE

Laboratory Demographics

CLIA Number: 11D2259716

Facility Name: VIDALIA IMMEDIATE AND PRIMARY CARE

Facility Address:
122 ALICE COLEMAN DRIVE
VIDALIA, GA
ZIP 30474
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Facility Phone Number: 912 805-2273

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1942974167

Taxonomy: 261QP2300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	11D2259716
LAB Type	Physician Office
Facility Name	VIDALIA IMMEDIATE AND PRIMARY CARE
Street	122 ALICE COLEMAN DRIVE
City	VIDALIA
State	GA
ZIP	30474
Phone	912 805-2273
CertificateType	4
CertificateEffectiveDate	5/10/2024
CertificateExpirationDate	5/9/2026
FacilityType	Waiver

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