03D2187472 CLIA NUMBER - PREMISE HEALTH OF ARIZONA MEDICAL PC

Laboratory Demographics

CLIA Number: 03D2187472

Facility Name: PREMISE HEALTH OF ARIZONA MEDICAL PC

Facility Address:
139 W COTTONWOOD LANE STE 107
CASA GRANDE, AZ
ZIP 85122
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Facility Phone Number: 303 921-0865

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1932872900

Taxonomy: 261QM1300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	03D2187472
LAB Type	Physician Office
Facility Name	PREMISE HEALTH OF ARIZONA MEDICAL PC
Street	139 W COTTONWOOD LANE STE 107
City	CASA GRANDE
State	AZ
ZIP	85122
Phone	303 921-0865
CertificateType	4
CertificateEffectiveDate	7/1/2022
CertificateExpirationDate	6/30/2024
FacilityType	Waiver

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