13D2178927 CLIA NUMBER - IDAHO MODERN MEDICINE

Laboratory Demographics

  • CLIA Code: 13D2178927
  • Facility Name: IDAHO MODERN MEDICINE
  • Facility Address: 1000 POCATELLO CR RD STE E10
    POCATELLO, ID
    ZIP 83201
  • Facility Phone: 208 648-4789
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: MICHAEL A. ANDERSON
  • NPI Number: 1184255754
  • Taxonomy: 207Q00000X - Family Medicine

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CLIA Record

Field Name Field Value
CLIA Number 13D2178927
LAB Type Physician Office
Facility Name IDAHO MODERN MEDICINE
Street 1000 POCATELLO CR RD STE E10
City POCATELLO
State ID
ZIP 83201
Phone 208 648-4789
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 2/11/2024
Certificate Expiration Date 2/10/2026
Facility Type Physician Office
Lab Director MICHAEL A. ANDERSON

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This page was last updated on: 6/4/2025