13D2193453 CLIA NUMBER - HENRY'S FORK SURGERY CENTER

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Laboratory Demographics

CLIA Number: 13D2193453

Facility Name: HENRY'S FORK SURGERY CENTER

Facility Address:
23 SAWTELLE AVE STE 101
REXBURG, ID
ZIP 83440
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Facility Phone Number: 208 356-0700

Facility Type: Ambulatory Surgery Center

Certificate Type: Waiver

NPI Number: 1235768490

Taxonomy: 261QA1903X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	13D2193453
LAB Type	Ambulatory Surgery Center
Facility Name	HENRY'S FORK SURGERY CENTER
Street	23 SAWTELLE AVE STE 101
City	REXBURG
State	ID
ZIP	83440
Phone	208 356-0700
CertificateType	4
CertificateEffectiveDate	9/22/2022
CertificateExpirationDate	9/21/2024
FacilityType	Waiver

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