49D2280070 CLIA NUMBER - BLUE MANTLE MEDICINE, PLLC

Laboratory Demographics

  • CLIA Code: 49D2280070
  • Facility Name: BLUE MANTLE MEDICINE, PLLC
  • Facility Address: 4001 FAIR RIDGE DR, SUITE #305
    FAIRFAX, VA
    ZIP 22033
  • Facility Phone: (540) 645-1856
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: SITA S. CANADY
  • NPI Number: 1417658980
  • Taxonomy: 208000000X - Pediatrics

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CLIA Record

Field Name Field Value
CLIA Number 49D2280070
LAB Type Physician Office
Facility Name BLUE MANTLE MEDICINE, PLLC
Street 4001 FAIR RIDGE DR, SUITE #305
City FAIRFAX
State VA
ZIP 22033
Phone 5406451856
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 4/12/2025
Certificate Expiration Date 4/11/2027
Facility Type Physician Office
Lab Director SITA S. CANADY

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This page was last updated on: 5/18/2026