13D0936394 CLIA NUMBER - IDAHO FALLS FAMILY & SPORTS MEDICINE

Laboratory Demographics

  • CLIA Code: 13D0936394
  • Facility Name: IDAHO FALLS FAMILY & SPORTS MEDICINE
  • Facility Address: 3360 WASHINGTON PKWY #1
    IDAHO FALLS, ID
    ZIP 83404
  • Facility Phone: (208) 524-3416
  • Facility Type: Physician Office
  • Facility Type: Microscopy
  • Lab Director: TONY C. ROISUM
  • NPI Number: 1124115944
  • Taxonomy: 207Q00000X - Family Medicine

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CLIA Record

Field Name Field Value
CLIA Number 13D0936394
LAB Type Physician Office
Facility Name IDAHO FALLS FAMILY & SPORTS MEDICINE
Street 3360 WASHINGTON PKWY #1
City IDAHO FALLS
State ID
ZIP 83404
Phone 2085243416
Certificate Type Certificate for Provider-Performed Microscopy Procedures (PPMP)
Certificate Type Description This certificate is issued to a laboratory in which a physician, midlevel practitioner or dentist performs no tests other than the microscopy procedures. This certificate permits the laboratory to also perform waived tests.
Certificate Effective Date 11/20/2025
Certificate Expiration Date 11/19/2027
Facility Type Physician Office
Lab Director TONY C. ROISUM

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This page was last updated on: 6/29/2026