14D0648270 CLIA NUMBER - SODERSTROM DERMATOLOGY CENTER SC

Laboratory Demographics

  • CLIA Code: 14D0648270
  • Facility Name: SODERSTROM DERMATOLOGY CENTER SC
  • Facility Address: 4909 N GLEN PARK PLACE
    PEORIA, IL
    ZIP 61614
  • Facility Phone: 309 674-7546
  • Facility Type: Ambulatory Surgery Center
  • Facility Type: Certificate of Compliance
  • Lab Director: JOSHUA B. KENTOSH
  • NPI Number: 1710931670
  • Taxonomy: 207N00000X - Dermatology

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CLIA Record

Field Name Field Value
CLIA Number 14D0648270
LAB Type Ambulatory Surgery Center
Facility Name SODERSTROM DERMATOLOGY CENTER SC
Street 4909 N GLEN PARK PLACE
City PEORIA
State IL
ZIP 61614
Phone 309 674-7546
Certificate Type Certificate of Compliance
Certificate Type Description This certificate is issued to a laboratory after an inspection that finds the laboratory to be in compliance with all applicable CLIA requirements.
Certificate Effective Date 8/17/2024
Certificate Expiration Date 8/16/2026
Facility Type Ambulatory Surgery Center
Lab Director JOSHUA B. KENTOSH

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