04D1089069 CLIA NUMBER - AIR-EVAC 12

Laboratory Demographics

  • CLIA Code: 04D1089069
  • Facility Name: AIR-EVAC 12
  • Facility Address: 549 HOSPITAL DRIVE
    MOUNTAIN HOME, AR
    ZIP 72653
  • Facility Phone: 870 508-2611
  • Facility Type: Ambulance
  • Facility Type: Waiver
  • Lab Director: LACEY ROBB
  • NPI Number: 1699758409
  • Taxonomy: 3416A0800X - Ambulance

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CLIA Record

Field Name Field Value
CLIA Number 04D1089069
LAB Type Ambulance
Facility Name AIR-EVAC 12
Street 549 HOSPITAL DRIVE
City MOUNTAIN HOME
State AR
ZIP 72653
Phone 870 508-2611
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 9/10/2024
Certificate Expiration Date 9/9/2026
Facility Type Ambulance
Lab Director LACEY ROBB

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