49D2212831 CLIA NUMBER - MAYO MEDICAL PRACTICE, LLC

Laboratory Demographics

  • CLIA Code: 49D2212831
  • Facility Name: MAYO MEDICAL PRACTICE, LLC
  • Facility Address: 563 SOUTHPARK BOULEVARD
    COLONIAL HEIGHTS, VA
    ZIP 23834
  • Facility Phone: 218 207-8373
  • Facility Type: Practitioner Other
  • Facility Type: Waiver
  • Lab Director: EDWAN T. KIBOT
  • NPI Number: 1891391843
  • Taxonomy: 364SF0001X - Clinical Nurse Specialist

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CLIA Record

Field Name Field Value
CLIA Number 49D2212831
LAB Type Practitioner Other
Facility Name MAYO MEDICAL PRACTICE, LLC
Street 563 SOUTHPARK BOULEVARD
City COLONIAL HEIGHTS
State VA
ZIP 23834
Phone 218 207-8373
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 2/8/2025
Certificate Expiration Date 2/7/2027
Facility Type Practitioner Other
Lab Director EDWAN T. KIBOT

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