44D2085219 CLIA NUMBER - KAFUL (DOUBLE PORTION) FAMILY PRACTICE

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Laboratory Demographics

CLIA Number: 44D2085219

Facility Name: KAFUL (DOUBLE PORTION) FAMILY PRACTICE

Facility Address:
3740 OCOEE PLACE NW, SUITE 101
CLEVELAND, TN
ZIP 37312
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Facility Phone Number: 423 339-7107

Facility Type: Practitioner Other

Certificate Type: Waiver

NPI Number: 1386049476

Taxonomy: 363LF0000X - Nurse Practitioner

CLIA Record

Field Name	Field Value
CLIA Number	44D2085219
LAB Type	Practitioner Other
Facility Name	KAFUL (DOUBLE PORTION) FAMILY PRACTICE
Street	3740 OCOEE PLACE NW, SUITE 101
City	CLEVELAND
State	TN
ZIP	37312
Phone	423 339-7107
CertificateType	4
CertificateEffectiveDate	10/9/2022
CertificateExpirationDate	10/8/2024
FacilityType	Waiver

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