06D1094406 CLIA NUMBER - PREMISE HEALTH OF COLORADO MEDICAL PC

Laboratory Demographics

CLIA Number: 06D1094406

Facility Name: PREMISE HEALTH OF COLORADO MEDICAL PC

Facility Address:
1675 GARDEN OF THE GODS RD STE 1053
CO SPGS, CO
ZIP 80907
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Facility Phone Number: 719 520-7600

Facility Type: Practitioner Other

Certificate Type: Waiver

NPI Number: 1194498162

Taxonomy: 261QM1300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	06D1094406
LAB Type	Practitioner Other
Facility Name	PREMISE HEALTH OF COLORADO MEDICAL PC
Street	1675 GARDEN OF THE GODS RD STE 1053
City	CO SPGS
State	CO
ZIP	80907
Phone	719 520-7600
CertificateType	4
CertificateEffectiveDate	1/19/2023
CertificateExpirationDate	1/18/2025
FacilityType	Waiver

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