21D2158891 CLIA NUMBER - CUSTOM MADE WEIGHT LOSS AND WELLNESS SOLUTIONS

Laboratory Demographics

CLIA Number: 21D2158891

Facility Name: CUSTOM MADE WEIGHT LOSS AND WELLNESS SOLUTIONS

Facility Address:
372 MAIN ST
LAUREL, MD
ZIP 20707
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Facility Phone Number: (240) 294-2079

Facility Type: OTHER PRACTITIONER

Certificate Type: Waiver

NPI Number: 1093361057

Taxonomy: 363LF0000X - Nurse Practitioner

CLIA Record

Field Name	Field Value
CLIA Number	21D2158891
LAB Type	OTHER PRACTITIONER
Facility Name	CUSTOM MADE WEIGHT LOSS AND WELLNESS SOLUTIONS
Street	372 MAIN ST
City	LAUREL
State	MD
ZIP	20707
Phone	(240) 294-2079

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This page was last updated on: 5/11/2023