02D2165694 CLIA NUMBER - MOOSE CREEK MEDICAL CLINIC, LLC

Laboratory Demographics

CLIA Number: 02D2165694

Facility Name: MOOSE CREEK MEDICAL CLINIC, LLC

Facility Address:
211 E FAIRVIEW LOOP
WASILLA, AK
ZIP 99654
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Facility Phone Number: 907 373-3335

Facility Type: Practitioner Other

Certificate Type: Microscopy

NPI Number: 1053883595

Taxonomy: 363LA2200X - Nurse Practitioner

CLIA Record

Field Name	Field Value
CLIA Number	02D2165694
LAB Type	Practitioner Other
Facility Name	MOOSE CREEK MEDICAL CLINIC, LLC
Street	211 E FAIRVIEW LOOP
City	WASILLA
State	AK
ZIP	99654
Phone	907 373-3335
CertificateType	3
CertificateEffectiveDate	5/3/2023
CertificateExpirationDate	5/2/2025
FacilityType	PPMP

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