25D1103896 CLIA NUMBER - PREMISE HEALTH OF MISSISSIPPI MEDICAL PC

Laboratory Demographics

CLIA Number: 25D1103896

Facility Name: PREMISE HEALTH OF MISSISSIPPI MEDICAL PC

Facility Address:
6311 RIDGEWOOD RD
JACKSON, MS
ZIP 39215
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Facility Phone Number: 601 213-0929

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1942346465

Taxonomy: 251K00000X - Public Health or Welfare

CLIA Record

Field Name	Field Value
CLIA Number	25D1103896
LAB Type	Physician Office
Facility Name	PREMISE HEALTH OF MISSISSIPPI MEDICAL PC
Street	6311 RIDGEWOOD RD
City	JACKSON
State	MS
ZIP	39215
Phone	601 213-0929
CertificateType	4
CertificateEffectiveDate	8/20/2023
CertificateExpirationDate	8/19/2025
FacilityType	Waiver

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