13D2113001 CLIA NUMBER - TABLE ROCK MOBILE MEDICINE PLLC

Laboratory Demographics

  • CLIA Code: 13D2113001
  • Facility Name: TABLE ROCK MOBILE MEDICINE PLLC
  • Facility Address: 3090 GENTRY WAY STE 210
    MERIDIAN, ID
    ZIP 83642
  • Facility Phone: 986 224-8280
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: BRADLEY A. BIGFORD
  • NPI Number: 1194186437
  • Taxonomy: 363LF0000X - Nurse Practitioner

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CLIA Record

Field Name Field Value
CLIA Number 13D2113001
LAB Type Physician Office
Facility Name TABLE ROCK MOBILE MEDICINE PLLC
Street 3090 GENTRY WAY STE 210
City MERIDIAN
State ID
ZIP 83642
Phone 986 224-8280
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 5/13/2024
Certificate Expiration Date 5/12/2026
Facility Type Physician Office
Lab Director BRADLEY A. BIGFORD

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This page was last updated on: 9/29/2025