25D2304952 CLIA NUMBER - SUPERIORCARE MEDICAL GROUP LLC

Laboratory Demographics

  • CLIA Code: 25D2304952
  • Facility Name: SUPERIORCARE MEDICAL GROUP LLC
  • Facility Address: 1223 MAINE STREET
    SOUTHAVEN, MS
    ZIP 38671
  • Facility Phone: 662 408-6995
  • Facility Type: Practitioner Other
  • Facility Type: Waiver
  • Lab Director: DONNA J. LUCKETT
  • NPI Number: 1124802178
  • Taxonomy: 363LF0000X - Nurse Practitioner

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CLIA Record

Field Name Field Value
CLIA Number 25D2304952
LAB Type Practitioner Other
Facility Name SUPERIORCARE MEDICAL GROUP LLC
Street 1223 MAINE STREET
City SOUTHAVEN
State MS
ZIP 38671
Phone 662 408-6995
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 5/21/2024
Certificate Expiration Date 5/20/2026
Facility Type Practitioner Other
Lab Director DONNA J. LUCKETT

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