13D0520280 CLIA NUMBER - PHS MD #2 LLC

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Laboratory Demographics

CLIA Number: 13D0520280

Facility Name: PHS MD #2 LLC

Facility Address:
1151 # A HOSPITAL WAY
POCATELLO, ID
ZIP 83201
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Facility Phone Number: 208 232-6616

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1760719454

Taxonomy: 261QM1300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	13D0520280
LAB Type	Physician Office
Facility Name	PHS MD #2 LLC
Street	1151 # A HOSPITAL WAY
City	POCATELLO
State	ID
ZIP	83201
Phone	208 232-6616
CertificateType	4
CertificateEffectiveDate	10/29/2022
CertificateExpirationDate	10/28/2024
FacilityType	Waiver

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