45D2217629 CLIA NUMBER - VISAGE INTEGRATIVE MEDICINE

Laboratory Demographics

CLIA Number: 45D2217629

Facility Name: VISAGE INTEGRATIVE MEDICINE

Facility Address:
3144 EXECUTIVE DRIVE
SAN ANGELO, TX
ZIP 76904
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Facility Phone Number: 325 617-4594

Facility Type: Practitioner Other

Certificate Type: Waiver

NPI Number: 1497345003

Taxonomy: 363LF0000X - Nurse Practitioner

CLIA Record

Field Name	Field Value
CLIA Number	45D2217629
LAB Type	Practitioner Other
Facility Name	VISAGE INTEGRATIVE MEDICINE
Street	3144 EXECUTIVE DRIVE
City	SAN ANGELO
State	TX
ZIP	76904
Phone	325 617-4594
CertificateType	4
CertificateEffectiveDate	3/23/2023
CertificateExpirationDate	3/22/2025
FacilityType	Waiver

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