03D2072275 CLIA NUMBER - CCR-OTC LLC

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Laboratory Demographics

CLIA Number: 03D2072275

Facility Name: CCR-OTC LLC

Facility Address:
819 W GURLEY ST STE A&C
PRESCOTT, AZ
ZIP 86305
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Facility Phone Number: 928 671-0161

Facility Type: Other - CO-IOP

Certificate Type: Waiver

NPI Number: 1700281219

Taxonomy: 261QR0405X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	03D2072275
LAB Type	Other - CO-IOP
Facility Name	CCR-OTC LLC
Street	819 W GURLEY ST STE A&C
City	PRESCOTT
State	AZ
ZIP	86305
Phone	928 671-0161
CertificateType	4
CertificateEffectiveDate	1/28/2024
CertificateExpirationDate	1/27/2026
FacilityType	Waiver

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