25D2086325 CLIA NUMBER - OLD TOWNE MEDICAL LLC

Laboratory Demographics

  • CLIA Code: 25D2086325
  • Facility Name: OLD TOWNE MEDICAL LLC
  • Facility Address: 9066 HIGHLAND STREET
    OLIVE BRANCH, MS
    ZIP 38654
  • Facility Phone: 662 874-6164
  • Facility Type: Practitioner Other
  • Facility Type: Waiver
  • Lab Director: SUSAN BRAME
  • NPI Number: 1013312172
  • Taxonomy: 363LF0000X - Nurse Practitioner

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CLIA Record

Field Name Field Value
CLIA Number 25D2086325
LAB Type Practitioner Other
Facility Name OLD TOWNE MEDICAL LLC
Street 9066 HIGHLAND STREET
City OLIVE BRANCH
State MS
ZIP 38654
Phone 662 874-6164
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 10/31/2024
Certificate Expiration Date 10/30/2026
Facility Type Practitioner Other
Lab Director SUSAN BRAME

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