13D2212951 CLIA NUMBER - SOUTH CUSTER AMBULANCE

Laboratory Demographics

CLIA Number: 13D2212951

Facility Name: SOUTH CUSTER AMBULANCE

Facility Address:
201 MCCALEB AVE
MACKAY, ID
ZIP 83251
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Facility Phone Number: 208 589-5747

Facility Type: Ambulance

Certificate Type: Waiver

NPI Number: 1487764551

Taxonomy: 3416L0300X - Ambulance

CLIA Record

Field Name	Field Value
CLIA Number	13D2212951
LAB Type	Ambulance
Facility Name	SOUTH CUSTER AMBULANCE
Street	201 MCCALEB AVE
City	MACKAY
State	ID
ZIP	83251
Phone	208 589-5747
CertificateType	4
CertificateEffectiveDate	2/9/2023
CertificateExpirationDate	2/8/2025
FacilityType	Waiver

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