04D2186272 CLIA NUMBER - OCH BENTON COUNTY CLINIC

Laboratory Demographics

  • CLIA Code: 04D2186272
  • Facility Name: OCH BENTON COUNTY CLINIC
  • Facility Address: 102 RUSSELL RD
    ROGERS, AR
    ZIP 72756
  • Facility Phone: 479 278-7189
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: DR. VIJAY KANNUM
  • NPI Number: 1154945483
  • Taxonomy: 261QR1300X - Clinic/Center

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CLIA Record

Field Name Field Value
CLIA Number 04D2186272
LAB Type Physician Office
Facility Name OCH BENTON COUNTY CLINIC
Street 102 RUSSELL RD
City ROGERS
State AR
ZIP 72756
Phone 479 278-7189
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 6/16/2024
Certificate Expiration Date 6/15/2026
Facility Type Physician Office
Lab Director DR. VIJAY KANNUM

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