03D1071752 CLIA NUMBER - BANNER PHYSICIAN SUPER SPECIALISTS ARIZONA LLC

Laboratory Demographics

CLIA Number: 03D1071752

Facility Name: BANNER PHYSICIAN SUPER SPECIALISTS ARIZONA LLC

Facility Address:
5310 W THUNDERBIRD RD, SUITE 301
GLENDALE, AZ
ZIP 85306
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Facility Phone Number: 602 865-4442

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1578125738

Taxonomy: 133NN1002X - Nutritionist

CLIA Record

Field Name	Field Value
CLIA Number	03D1071752
LAB Type	Physician Office
Facility Name	BANNER PHYSICIAN SUPER SPECIALISTS ARIZONA LLC
Street	5310 W THUNDERBIRD RD, SUITE 301
City	GLENDALE
State	AZ
ZIP	85306
Phone	602 865-4442
CertificateType	4
CertificateEffectiveDate	1/11/2024
CertificateExpirationDate	1/10/2026
FacilityType	Waiver

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