06D0881220 CLIA NUMBER - CANON PROFESSIONAL WELLNESS CLINIC, LLC

Laboratory Demographics

  • CLIA Code: 06D0881220
  • Facility Name: CANON PROFESSIONAL WELLNESS CLINIC, LLC
  • Facility Address: 730 MACON AVENUE
    CANON CITY, CO
    ZIP 81212
  • Facility Phone: 719 275-1618
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: LESLIE K. NELSON
  • NPI Number: 1568625549
  • Taxonomy: 261QP2300X - Clinic/Center

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CLIA Record

Field Name Field Value
CLIA Number 06D0881220
LAB Type Physician Office
Facility Name CANON PROFESSIONAL WELLNESS CLINIC, LLC
Street 730 MACON AVENUE
City CANON CITY
State CO
ZIP 81212
Phone 719 275-1618
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 12/10/2024
Certificate Expiration Date 12/9/2026
Facility Type Physician Office
Lab Director LESLIE K. NELSON

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