14D0698997 CLIA NUMBER - ILLINI FAMILY MEDICINE

Laboratory Demographics

CLIA Number: 14D0698997

Facility Name: ILLINI FAMILY MEDICINE

Facility Address:
2900 FRANK SCOTT PARKWAY WEST SUITE 980
BELLEVILLE, IL
ZIP 62223
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Facility Phone Number: 618 234-9200

Facility Type: Federally Qualified Health Center

Certificate Type: Waiver

NPI Number: 1255880647

Taxonomy: 261QF0400X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	14D0698997
LAB Type	Federally Qualified Health Center
Facility Name	ILLINI FAMILY MEDICINE
Street	2900 FRANK SCOTT PARKWAY WEST SUITE 980
City	BELLEVILLE
State	IL
ZIP	62223
Phone	618 234-9200
CertificateType	4
CertificateEffectiveDate	9/1/2022
CertificateExpirationDate	8/31/2024
FacilityType	Waiver

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