21D2206389 CLIA NUMBER - PERIDOT PRIMARY CARE LLC

Laboratory Demographics

  • CLIA Code: 21D2206389
  • Facility Name: PERIDOT PRIMARY CARE LLC
  • Facility Address: 23202 BREWERS TAVERN WAY
    CLARKSBURG, MD
    ZIP 20871
  • Facility Phone: 301 215-2309
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: PRINCESS STEPHENSON
  • NPI Number: 1356957252
  • Taxonomy: 363LF0000X - Nurse Practitioner

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CLIA Record

Field Name Field Value
CLIA Number 21D2206389
LAB Type Physician Office
Facility Name PERIDOT PRIMARY CARE LLC
Street 23202 BREWERS TAVERN WAY
City CLARKSBURG
State MD
ZIP 20871
Phone 301 215-2309
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 12/18/2024
Certificate Expiration Date 12/17/2026
Facility Type Physician Office
Lab Director PRINCESS STEPHENSON

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