25D0866749 CLIA NUMBER - JACKSON SOUTH DIALYSIS

Laboratory Demographics

  • CLIA Code: 25D0866749
  • Facility Name: JACKSON SOUTH DIALYSIS
  • Facility Address: 1015 I-20 FRONTAGE RD
    JACKSON, MS
    ZIP 39204
  • Facility Phone: 601 373-9154
  • Facility Type: End Stage Renal Disease Dialysis Facility
  • Facility Type: Waiver
  • Lab Director: GARY DAVIS
  • NPI Number: 1710932090
  • Taxonomy: 261QE0700X - Clinic/Center

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CLIA Record

Field Name Field Value
CLIA Number 25D0866749
LAB Type End Stage Renal Disease Dialysis Facility
Facility Name JACKSON SOUTH DIALYSIS
Street 1015 I-20 FRONTAGE RD
City JACKSON
State MS
ZIP 39204
Phone 601 373-9154
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 9/1/2024
Certificate Expiration Date 8/31/2026
Facility Type End Stage Renal Disease Dialysis Facility
Lab Director GARY DAVIS

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