45D2306063 CLIA NUMBER - ITASCA HEALING MEDICAL PRACTICE

Laboratory Demographics

  • CLIA Code: 45D2306063
  • Facility Name: ITASCA HEALING MEDICAL PRACTICE
  • Facility Address: 223 KING ST
    NACOGDOCHES, TX
    ZIP 75961
  • Facility Phone: 936 622-0552
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: SUZANNA FULLER
  • NPI Number: 1023867546
  • Taxonomy: 207Q00000X - Family Medicine

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CLIA Record

Field Name Field Value
CLIA Number 45D2306063
LAB Type Physician Office
Facility Name ITASCA HEALING MEDICAL PRACTICE
Street 223 KING ST
City NACOGDOCHES
State TX
ZIP 75961
Phone 936 622-0552
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 6/11/2024
Certificate Expiration Date 6/10/2026
Facility Type Physician Office
Lab Director SUZANNA FULLER

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