25D2071075 CLIA NUMBER - KOSCIUSKO VA PRIMARY CARE CENTER

Laboratory Demographics

  • CLIA Code: 25D2071075
  • Facility Name: KOSCIUSKO VA PRIMARY CARE CENTER
  • Facility Address: 405 WEST ADAMS STREET
    KOSCIUSKO, MS
    ZIP 39090
  • Facility Phone: 662 289-2880
  • Facility Type: Community Clinic
  • Facility Type: Waiver
  • Lab Director: MICHAEL HOLMAN
  • NPI Number: 1689952335
  • Taxonomy: 302F00000X - Exclusive Provider Organization

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CLIA Record

Field Name Field Value
CLIA Number 25D2071075
LAB Type Community Clinic
Facility Name KOSCIUSKO VA PRIMARY CARE CENTER
Street 405 WEST ADAMS STREET
City KOSCIUSKO
State MS
ZIP 39090
Phone 662 289-2880
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 1/2/2024
Certificate Expiration Date 1/1/2026
Facility Type Community Clinic
Lab Director MICHAEL HOLMAN

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