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45D1037921 CLIA NUMBER - EXECUTIVE MEDICINE OF SOUTHLAKE

Laboratory Demographics

CLIA Number: 45D1037921

Facility Name: EXECUTIVE MEDICINE OF SOUTHLAKE

Facility Address:
2106 E STATE HIGHWAY 114 SUITE 300
SOUTHLAKE, TX
ZIP 76092
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Facility Phone Number: 817 552-4300

Facility Type: Physician Office

Certificate Type: Waiver
NPI Number: 1043720154

Taxonomy: 207Q00000X - Family Medicine
Family Medicine is the medical specialty which is concerned with the total health care of the individual and the family. It is the specialty in breadth which integrates the biological, clinical, and behavioral sciences. The scope of family medicine is not limited by age, sex, organ system, or disease entity.

CLIA Record

Field Name Field Value
CLIA Number 45D1037921
LAB Type Physician Office
Facility Name EXECUTIVE MEDICINE OF SOUTHLAKE
Street 2106 E STATE HIGHWAY 114 SUITE 300
City SOUTHLAKE
State TX
ZIP 76092
Phone 817 552-4300
CertificateType 4
CertificateEffectiveDate 10/29/2023
CertificateExpirationDate 10/28/2025
FacilityType Waiver

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