19D1077682 CLIA NUMBER - BROADMOOR DIALYSIS

Laboratory Demographics

  • CLIA Code: 19D1077682
  • Facility Name: BROADMOOR DIALYSIS
  • Facility Address: 1815 E 70TH STREET
    SHREVEPORT, LA
    ZIP 71105
  • Facility Phone: 318 795-0572
  • Facility Type: End Stage Renal Disease Dialysis Facility
  • Facility Type: Waiver
  • Lab Director: MARISA T. JOHNSON MD
  • NPI Number: 1821122904
  • Taxonomy: 111N00000X - Chiropractor

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CLIA Record

Field Name Field Value
CLIA Number 19D1077682
LAB Type End Stage Renal Disease Dialysis Facility
Facility Name BROADMOOR DIALYSIS
Street 1815 E 70TH STREET
City SHREVEPORT
State LA
ZIP 71105
Phone 318 795-0572
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 12/17/2023
Certificate Expiration Date 12/16/2025
Facility Type End Stage Renal Disease Dialysis Facility
Lab Director MARISA T. JOHNSON MD

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