45D2039129 CLIA NUMBER - PROVINCIAL PARK SURGERY CENTER

Laboratory Demographics

  • CLIA Code: 45D2039129
  • Facility Name: PROVINCIAL PARK SURGERY CENTER
  • Facility Address: 21300 PROVINCIAL BLVD STE 200
    KATY, TX
    ZIP 77450
  • Facility Phone: 713 554-6350
  • Facility Type: Ambulatory Surgery Center
  • Facility Type: Waiver
  • Lab Director: MENNEN GALLAS
  • NPI Number: 1215204268
  • Taxonomy: 261QA1903X - Clinic/Center

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CLIA Record

Field Name Field Value
CLIA Number 45D2039129
LAB Type Ambulatory Surgery Center
Facility Name PROVINCIAL PARK SURGERY CENTER
Street 21300 PROVINCIAL BLVD STE 200
City KATY
State TX
ZIP 77450
Phone 713 554-6350
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 4/2/2024
Certificate Expiration Date 4/1/2026
Facility Type Ambulatory Surgery Center
Lab Director MENNEN GALLAS

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This page was last updated on: 9/29/2025