25D2142188 CLIA NUMBER - DESOTO FAMILY CARE CLINIC, PLLC

Laboratory Demographics

  • CLIA Code: 25D2142188
  • Facility Name: DESOTO FAMILY CARE CLINIC, PLLC
  • Facility Address: 346 STATELINE ROAD
    SOUTHAVEN, MS
    ZIP 38671
  • Facility Phone: 662 313-5417
  • Facility Type: Practitioner Other
  • Facility Type: Microscopy
  • Lab Director: DIOSAN M. POWELL
  • NPI Number: 1114469640
  • Taxonomy: 235Z00000X - Speech-Language Pathologist

Map and Directions

Get Directions

CLIA Record

Field Name Field Value
CLIA Number 25D2142188
LAB Type Practitioner Other
Facility Name DESOTO FAMILY CARE CLINIC, PLLC
Street 346 STATELINE ROAD
City SOUTHAVEN
State MS
ZIP 38671
Phone 662 313-5417
Certificate Type Certificate for Provider-Performed Microscopy Procedures (PPMP)
Certificate Type Description This certificate is issued to a laboratory in which a physician, midlevel practitioner or dentist performs no tests other than the microscopy procedures. This certificate permits the laboratory to also perform waived tests.
Certificate Effective Date 1/4/2024
Certificate Expiration Date 1/3/2026
Facility Type Practitioner Other
Lab Director DIOSAN M. POWELL

Download Record

Download this CLIA record record in Text format: Export

Download this CLIA record record in Excel (CSV) format: Export

Download this CLIA record record in XML format: Export

This page was last updated on: 6/4/2025