42D0248828 CLIA NUMBER - COULTER CLINIC, LLC

Laboratory Demographics

CLIA Number: 42D0248828

Facility Name: COULTER CLINIC, LLC

Facility Address:
941 SUMMERS AVENUE
ORANGEBURG, SC
ZIP 29115
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Facility Phone Number: 803 534-0437

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1609058254

Taxonomy: 261QP2300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	42D0248828
LAB Type	Physician Office
Facility Name	COULTER CLINIC, LLC
Street	941 SUMMERS AVENUE
City	ORANGEBURG
State	SC
ZIP	29115
Phone	803 534-0437
CertificateType	4
CertificateEffectiveDate	5/3/2023
CertificateExpirationDate	5/2/2025
FacilityType	Waiver

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