03D2157689 CLIA NUMBER - EBONY HOUSE, INC - INTEGRATED CARE

Laboratory Demographics

CLIA Number: 03D2157689

Facility Name: EBONY HOUSE, INC - INTEGRATED CARE

Facility Address:
1616 E INDIAN SCHOOL ROAD, SUITE 250
PHOENIX, AZ
ZIP 85016
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Facility Phone Number: 602 276-4288

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1710161419

Taxonomy: 101YA0400X - Counselor

CLIA Record

Field Name	Field Value
CLIA Number	03D2157689
LAB Type	Physician Office
Facility Name	EBONY HOUSE, INC - INTEGRATED CARE
Street	1616 E INDIAN SCHOOL ROAD, SUITE 250
City	PHOENIX
State	AZ
ZIP	85016
Phone	602 276-4288
CertificateType	4
CertificateEffectiveDate	11/9/2022
CertificateExpirationDate	11/8/2024
FacilityType	Waiver

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