13D0982472 CLIA NUMBER - PORTNEUF ASC LLC DBA PORTNEUF ENDOSCOPY CENTER

Laboratory Demographics

CLIA Number: 13D0982472

Facility Name: PORTNEUF ASC LLC DBA PORTNEUF ENDOSCOPY CENTER

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

Facility Type: Ambulatory Surgery Center

Certificate Type: Waiver

NPI Number: 1871016071

Taxonomy: 261QA1903X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	13D0982472
LAB Type	Ambulatory Surgery Center
Facility Name	PORTNEUF ASC LLC DBA PORTNEUF ENDOSCOPY CENTER
Street	1151 #A HOSPITAL WAY
City	POCATELLO
State	ID
ZIP	83201
Phone	208 232-6616
CertificateType	4
CertificateEffectiveDate	1/26/2023
CertificateExpirationDate	1/25/2025
FacilityType	Waiver

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