45D2112860 CLIA NUMBER - PEDIATRICA OF HERITAGE TRACE

Laboratory Demographics

  • CLIA Code: 45D2112860
  • Facility Name: PEDIATRICA OF HERITAGE TRACE
  • Facility Address: 9509 NORTH BEACH STREET SUITE 102
    FORT WORTH, TX
    ZIP 76244
  • Facility Phone: 817 617-8600
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: KATHRYN K. MANDAL
  • NPI Number: 1255147120
  • Taxonomy: 208000000X - Pediatrics

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CLIA Record

Field Name Field Value
CLIA Number 45D2112860
LAB Type Physician Office
Facility Name PEDIATRICA OF HERITAGE TRACE
Street 9509 NORTH BEACH STREET SUITE 102
City FORT WORTH
State TX
ZIP 76244
Phone 817 617-8600
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 5/10/2024
Certificate Expiration Date 5/9/2026
Facility Type Physician Office
Lab Director KATHRYN K. MANDAL

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