45D2121455 CLIA NUMBER - PREMISE HEALTH OF TEXAS MEDICAL, PA

Laboratory Demographics

CLIA Number: 45D2121455

Facility Name: PREMISE HEALTH OF TEXAS MEDICAL, PA

Facility Address:
4501 CREWMEMBER WAY MD SV5 - 900
FORT WORTH, TX
ZIP 76155
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Facility Phone Number: 682 278-8005

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1952756355

Taxonomy: 261QM1300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	45D2121455
LAB Type	Physician Office
Facility Name	PREMISE HEALTH OF TEXAS MEDICAL, PA
Street	4501 CREWMEMBER WAY MD SV5 - 900
City	FORT WORTH
State	TX
ZIP	76155
Phone	682 278-8005
CertificateType	4
CertificateEffectiveDate	11/4/2022
CertificateExpirationDate	11/3/2024
FacilityType	Waiver

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