04D1079751 CLIA NUMBER - CHANGE CENTER FOR HEALTH

Laboratory Demographics

CLIA Number: 04D1079751

Facility Name: CHANGE CENTER FOR HEALTH

Facility Address:
425 W CAPITOL AVE, SUITE 210
LITTLE ROCK, AR
ZIP 72201
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Facility Phone Number: 501 324-2643

Facility Type: Practitioner Other

Certificate Type: Waiver

NPI Number: 1720390362

Taxonomy: 363LF0000X - Nurse Practitioner

CLIA Record

Field Name	Field Value
CLIA Number	04D1079751
LAB Type	Practitioner Other
Facility Name	CHANGE CENTER FOR HEALTH
Street	425 W CAPITOL AVE, SUITE 210
City	LITTLE ROCK
State	AR
ZIP	72201
Phone	501 324-2643
CertificateType	4
CertificateEffectiveDate	2/6/2024
CertificateExpirationDate	2/5/2026
FacilityType	Waiver

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