45D2123948 CLIA NUMBER - SOUTHLAKE PHYSICAL MEDICINE, PLLC

Laboratory Demographics

  • CLIA Code: 45D2123948
  • Facility Name: SOUTHLAKE PHYSICAL MEDICINE, PLLC
  • Facility Address: 1500 W SOUTHLAKE BLVD # 120
    SOUTHLAKE, TX
    ZIP 76092
  • Facility Phone: 817 898-7400
  • Facility Type: Practitioner Other
  • Facility Type: Waiver
  • Lab Director: GARY A. TIGGS
  • NPI Number: 1588144893
  • Taxonomy: 208D00000X - General Practice

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CLIA Record

Field Name Field Value
CLIA Number 45D2123948
LAB Type Practitioner Other
Facility Name SOUTHLAKE PHYSICAL MEDICINE, PLLC
Street 1500 W SOUTHLAKE BLVD # 120
City SOUTHLAKE
State TX
ZIP 76092
Phone 817 898-7400
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 1/5/2025
Certificate Expiration Date 1/4/2027
Facility Type Practitioner Other
Lab Director GARY A. TIGGS

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