13D1075545 CLIA NUMBER - ST LUKE'S CHILDREN'S TREASURE VALLEY PEDIATRICS

Laboratory Demographics

CLIA Number: 13D1075545

Facility Name: ST LUKE'S CHILDREN'S TREASURE VALLEY PEDIATRICS

Facility Address:
450 W STATE ST #100
EAGLE, ID
ZIP 83616
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Facility Phone Number: 208 939-1035

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1396121349

Taxonomy: 261QP2300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	13D1075545
LAB Type	Physician Office
Facility Name	ST LUKE'S CHILDREN'S TREASURE VALLEY PEDIATRICS
Street	450 W STATE ST #100
City	EAGLE
State	ID
ZIP	83616
Phone	208 939-1035
CertificateType	4
CertificateEffectiveDate	9/21/2022
CertificateExpirationDate	9/20/2024
FacilityType	Waiver

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