13D1076383 CLIA NUMBER - PHYSICIANS & SURGEONS CLINIC OF SHELLEY

Laboratory Demographics

  • CLIA Code: 13D1076383
  • Facility Name: PHYSICIANS & SURGEONS CLINIC OF SHELLEY
  • Facility Address: 275 W LOCUST ST
    SHELLEY, ID
    ZIP 83274
  • Facility Phone: 208 782-2960
  • Facility Type: Community Clinic
  • Facility Type: Waiver
  • Lab Director: KENNETH BLACKNER
  • NPI Number: 1366630949
  • Taxonomy: 261QR1300X - Clinic/Center

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CLIA Record

Field Name Field Value
CLIA Number 13D1076383
LAB Type Community Clinic
Facility Name PHYSICIANS & SURGEONS CLINIC OF SHELLEY
Street 275 W LOCUST ST
City SHELLEY
State ID
ZIP 83274
Phone 208 782-2960
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 12/26/2024
Certificate Expiration Date 12/25/2026
Facility Type Community Clinic
Lab Director KENNETH BLACKNER

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This page was last updated on: 9/29/2025