34D2031984 CLIA NUMBER - COASTAL SOUTHEASTERN FAMILY PRACTICE, PLLC

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Laboratory Demographics

CLIA Number: 34D2031984

Facility Name: COASTAL SOUTHEASTERN FAMILY PRACTICE, PLLC

Facility Address:
205 W THIRD STREET
PEMBROKE, NC
ZIP 28372
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Facility Phone Number: 910 521-0099

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1699067488

Taxonomy: 363LF0000X - Nurse Practitioner

CLIA Record

Field Name	Field Value
CLIA Number	34D2031984
LAB Type	Physician Office
Facility Name	COASTAL SOUTHEASTERN FAMILY PRACTICE, PLLC
Street	205 W THIRD STREET
City	PEMBROKE
State	NC
ZIP	28372
Phone	910 521-0099
CertificateType	4
CertificateEffectiveDate	11/2/2023
CertificateExpirationDate	11/1/2025
FacilityType	Waiver

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