03D0942439 CLIA NUMBER - MOUNTAIN AVENUE CLINIC

Laboratory Demographics

  • CLIA Code: 03D0942439
  • Facility Name: MOUNTAIN AVENUE CLINIC
  • Facility Address: 606 N MAIN STREET
    EAGAR, AZ
    ZIP 85925
  • Facility Phone: 928 333-5333
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: RALPH PETERSON
  • NPI Number: 1790974830
  • Taxonomy: 207R00000X - Internal Medicine

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CLIA Record

Field Name Field Value
CLIA Number 03D0942439
LAB Type Physician Office
Facility Name MOUNTAIN AVENUE CLINIC
Street 606 N MAIN STREET
City EAGAR
State AZ
ZIP 85925
Phone 928 333-5333
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 3/11/2024
Certificate Expiration Date 3/10/2026
Facility Type Physician Office
Lab Director RALPH PETERSON

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