49D2159857 CLIA NUMBER - EXECUTIVE HEALTHCARE SERVICES

Laboratory Demographics

  • CLIA Code: 49D2159857
  • Facility Name: EXECUTIVE HEALTHCARE SERVICES
  • Facility Address: 12040 SOUTH LAKES DR #204
    RESTON, VA
    ZIP 20191
  • Facility Phone: (703) 230-0347
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: KEVIN J. KELLEHER
  • NPI Number: 1760664007
  • Taxonomy: 207Q00000X - Family Medicine

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CLIA Record

Field Name Field Value
CLIA Number 49D2159857
LAB Type Physician Office
Facility Name EXECUTIVE HEALTHCARE SERVICES
Street 12040 SOUTH LAKES DR #204
City RESTON
State VA
ZIP 20191
Phone 7032300347
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 12/28/2024
Certificate Expiration Date 12/27/2026
Facility Type Physician Office
Lab Director KEVIN J. KELLEHER

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This page was last updated on: 6/29/2026