21D2280721 CLIA NUMBER - SUPREME HEALTHCARE & WELLNESS SERVICES LLC

Laboratory Demographics

CLIA Number: 21D2280721

Facility Name: SUPREME HEALTHCARE & WELLNESS SERVICES LLC

Facility Address:
12401 MIDDLEBROOK RD #190
GERMANTOWN, MD
ZIP 20874
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Facility Phone Number: 240 895-9010

Facility Type: Practitioner Other

Certificate Type: Waiver

NPI Number: 1215670047

Taxonomy: 261QM0801X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	21D2280721
LAB Type	Practitioner Other
Facility Name	SUPREME HEALTHCARE & WELLNESS SERVICES LLC
Street	12401 MIDDLEBROOK RD #190
City	GERMANTOWN
State	MD
ZIP	20874
Phone	240 895-9010
CertificateType	4
CertificateEffectiveDate	4/25/2023
CertificateExpirationDate	4/24/2025
FacilityType	Waiver

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This page was last updated on: 4/23/2024