14D0436466 CLIA NUMBER - MULBERRY MANOR INC

Laboratory Demographics

CLIA Code: 14D0436466
Facility Name: MULBERRY MANOR INC
Facility Address: 612 E DAVIE ST
ANNA, IL
ZIP 62906
Facility Phone: 618 833-6012
Facility Type: Intermediate Care Facility for Mentally Retarded
Facility Type: Waiver
Lab Director: AMBER FAIRLESS
NPI Number: 1164646550
Taxonomy: 320600000X - Residential Treatment Facility, Intellectual and/or Developmental Disabilities

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CLIA Record

Field Name	Field Value
CLIA Number	14D0436466
LAB Type	Intermediate Care Facility for Mentally Retarded
Facility Name	MULBERRY MANOR INC
Street	612 E DAVIE ST
City	ANNA
State	IL
ZIP	62906
Phone	618 833-6012
Certificate Type	Certificate of Waiver
Certificate Type Description	This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date	9/1/2024
Certificate Expiration Date	8/31/2026
Facility Type	Intermediate Care Facility for Mentally Retarded
Lab Director	AMBER FAIRLESS

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