11D2276167 CLIA NUMBER - HOMETOWN PEDIATRICS LLC

Laboratory Demographics

CLIA Number: 11D2276167

Facility Name: HOMETOWN PEDIATRICS LLC

Facility Address:
108 N 4TH STREET
VIENNA, GA
ZIP 31092
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Facility Phone Number: 229 231-5008

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1013623263

Taxonomy: 261QM2500X - Clinic/Center
An entity, facility, or distinct part of a facility providing diagnostic, treatment, and prescriptive services related to a specific area of medical specialization. Frequently used for Title V related Children's Specialty services or to meet specific public health needs (e.g., infectious diseases or breast and cervical cancer).

CLIA Record

Field Name	Field Value
CLIA Number	11D2276167
LAB Type	Physician Office
Facility Name	HOMETOWN PEDIATRICS LLC
Street	108 N 4TH STREET
City	VIENNA
State	GA
ZIP	31092
Phone	229 231-5008
CertificateType	4
CertificateEffectiveDate	2/3/2023
CertificateExpirationDate	2/2/2025
FacilityType	Waiver

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