03D2211681 CLIA NUMBER - BANNER PHYSICIAN SUPER SPECIALISTS ARIZONA LLC

Laboratory Demographics

CLIA Number: 03D2211681

Facility Name: BANNER PHYSICIAN SUPER SPECIALISTS ARIZONA LLC

Facility Address:
1432 S DOBSON RD STE 301
MESA, AZ
ZIP 85202
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Facility Phone Number: 480 412-9400

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1396014403

Taxonomy: 261QM1300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	03D2211681
LAB Type	Physician Office
Facility Name	BANNER PHYSICIAN SUPER SPECIALISTS ARIZONA LLC
Street	1432 S DOBSON RD STE 301
City	MESA
State	AZ
ZIP	85202
Phone	480 412-9400
CertificateType	4
CertificateEffectiveDate	1/29/2023
CertificateExpirationDate	1/28/2025
FacilityType	Waiver

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