13D2268049 CLIA NUMBER - MOONLIGHT MOUNTAIN RECOVERY

Laboratory Demographics

  • CLIA Code: 13D2268049
  • Facility Name: MOONLIGHT MOUNTAIN RECOVERY
  • Facility Address: 2500 S FIFTH AVE STE B
    POCATELLO, ID
    ZIP 83201
  • Facility Phone: (801) 915-8542
  • Facility Type: Other - BEHAVIOR HEALTH PHP IOP
  • Facility Type: Waiver
  • Lab Director: WADE MORDEN
  • NPI Number: 1861983413
  • Taxonomy: 324500000X - Substance Abuse Rehabilitation Facility

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CLIA Record

Field Name Field Value
CLIA Number 13D2268049
LAB Type Other - BEHAVIOR HEALTH PHP IOP
Facility Name MOONLIGHT MOUNTAIN RECOVERY
Street 2500 S FIFTH AVE STE B
City POCATELLO
State ID
ZIP 83201
Phone 8019158542
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 9/6/2024
Certificate Expiration Date 9/5/2026
Facility Type Other - BEHAVIOR HEALTH PHP IOP
Lab Director WADE MORDEN

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This page was last updated on: 5/18/2026