51D2034168 CLIA NUMBER - PREMISE HEALTH OF WEST VIRGINIA MEDICAL, MEDICAL CORPORATION

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Laboratory Demographics

CLIA Number: 51D2034168

Facility Name: PREMISE HEALTH OF WEST VIRGINIA MEDICAL, MEDICAL CORPORATION

Facility Address:
1 SUGAR MAPLE LANE
BUFFALO, WV
ZIP 25033
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Facility Phone Number: 304 937-7426

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1619244472

Taxonomy: 261QX0100X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	51D2034168
LAB Type	Physician Office
Facility Name	PREMISE HEALTH OF WEST VIRGINIA MEDICAL, MEDICAL CORPORATION
Street	1 SUGAR MAPLE LANE
City	BUFFALO
State	WV
ZIP	25033
Phone	304 937-7426
CertificateType	4
CertificateEffectiveDate	12/19/2023
CertificateExpirationDate	12/18/2025
FacilityType	Waiver

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