44D2172788 CLIA NUMBER - PRESTIGE FAMILY MEDICINE

Laboratory Demographics

CLIA Number: 44D2172788

Facility Name: PRESTIGE FAMILY MEDICINE

Facility Address:
1409 W MARKET STREET SUITE 108
JOHNSON CITY, TN
ZIP 37604
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Facility Phone Number: 423 833-0033

Facility Type: Practitioner Other

Certificate Type: Waiver

NPI Number: 1730755083

Taxonomy: 363LF0000X - Nurse Practitioner

CLIA Record

Field Name	Field Value
CLIA Number	44D2172788
LAB Type	Practitioner Other
Facility Name	PRESTIGE FAMILY MEDICINE
Street	1409 W MARKET STREET SUITE 108
City	JOHNSON CITY
State	TN
ZIP	37604
Phone	423 833-0033
CertificateType	4
CertificateEffectiveDate	9/30/2023
CertificateExpirationDate	9/29/2025
FacilityType	Waiver

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