04D1059020 CLIA NUMBER - SOUTHEAST REHABILITATION HOSPITAL

Laboratory Demographics

  • CLIA Code: 04D1059020
  • Facility Name: SOUTHEAST REHABILITATION HOSPITAL
  • Facility Address: 905 BORGOGNONI DR
    LAKE VILLAGE, AR
    ZIP 71653
  • Facility Phone: 870 265-4333
  • Facility Type: Hospital
  • Facility Type: Waiver
  • Lab Director: DR. JOHN R. RUSSELL
  • NPI Number: 1194358523
  • Taxonomy: 261QR1300X - Clinic/Center

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CLIA Record

Field Name Field Value
CLIA Number 04D1059020
LAB Type Hospital
Facility Name SOUTHEAST REHABILITATION HOSPITAL
Street 905 BORGOGNONI DR
City LAKE VILLAGE
State AR
ZIP 71653
Phone 870 265-4333
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 9/20/2024
Certificate Expiration Date 9/19/2026
Facility Type Hospital
Lab Director DR. JOHN R. RUSSELL

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This page was last updated on: 9/29/2025