01D0692716 CLIA NUMBER - Jefferson Pediatrics Pc

Laboratory Demographics

CLIA Number: 01D0692716

Facility Name: Jefferson Pediatrics Pc

Facility Address:
3919 W Jefferson Blvd Ste 1,
Fort Wayne, IN
ZIP 46804
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Facility Phone Number: (260) 436-7722

Facility Type: PHYSICIAN OFFICE

Certificate Type: Waiver

NPI Number: 1134542855

Taxonomy: 363LF0000X - Nurse Practitioner

CLIA Record

Field Name	Field Value
CLIA Number	01D0692716
LAB Type	PHYSICIAN OFFICE
Facility Name	Jefferson Pediatrics Pc
Street	3919 W Jefferson Blvd Ste 1,
City	Fort Wayne
State	IN
ZIP	46804
Phone	2604367722

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This page was last updated on: 5/19/2019