21D2167895 CLIA NUMBER - PRIME BEHAVIORAL HEALTH LLC

Laboratory Demographics

  • CLIA Code: 21D2167895
  • Facility Name: PRIME BEHAVIORAL HEALTH LLC
  • Facility Address: 13994 BALTIMORE AVENUE STE 102
    LAUREL, MD
    ZIP 20707
  • Facility Phone: 301 477-2128
  • Facility Type: Practitioner Other
  • Facility Type: Waiver
  • Lab Director: JULIUS FOMENGIA
  • NPI Number: 1164990818
  • Taxonomy: 261QM0801X - Clinic/Center

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CLIA Record

Field Name Field Value
CLIA Number 21D2167895
LAB Type Practitioner Other
Facility Name PRIME BEHAVIORAL HEALTH LLC
Street 13994 BALTIMORE AVENUE STE 102
City LAUREL
State MD
ZIP 20707
Phone 301 477-2128
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 6/18/2025
Certificate Expiration Date 6/17/2027
Facility Type Practitioner Other
Lab Director JULIUS FOMENGIA

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