45D1104766 CLIA NUMBER - BLUEBONNET TRAILS CMHMRC FAYETTE CO

Laboratory Demographics

CLIA Number: 45D1104766

Facility Name: BLUEBONNET TRAILS CMHMRC FAYETTE CO

Facility Address:
750 W TRAVIS ST
LA GRANGE, TX
ZIP 78945
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Facility Phone Number: 830 798-2854

Facility Type: Community Clinic

Certificate Type: Waiver

NPI Number: 1518536309

Taxonomy: 261QR1300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	45D1104766
LAB Type	Community Clinic
Facility Name	BLUEBONNET TRAILS CMHMRC FAYETTE CO
Street	750 W TRAVIS ST
City	LA GRANGE
State	TX
ZIP	78945
Phone	830 798-2854
CertificateType	4
CertificateEffectiveDate	9/10/2023
CertificateExpirationDate	9/9/2025
FacilityType	Waiver

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