14D0940457 CLIA NUMBER - MOUNT OLIVE FAMILY PRACTICE CENTER MACOUPIN FAMILY PRACTICE CENTERS LLP

Laboratory Demographics

CLIA Code: 14D0940457
Facility Name: MOUNT OLIVE FAMILY PRACTICE CENTER MACOUPIN FAMILY PRACTICE CENTERS LLP
Facility Address: 115 NORTH POPLAR
MOUNT OLIVE, IL
ZIP 62069
Facility Phone: 217 999-4751
Facility Type: Physician Office
Facility Type: Microscopy
Lab Director: BRUCE WEBER M D
NPI Number: 1558312322
Taxonomy: 251300000X - Local Education Agency (LEA)

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CLIA Record

Field Name	Field Value
CLIA Number	14D0940457
LAB Type	Physician Office
Facility Name	MOUNT OLIVE FAMILY PRACTICE CENTER MACOUPIN FAMILY PRACTICE CENTERS LLP
Street	115 NORTH POPLAR
City	MOUNT OLIVE
State	IL
ZIP	62069
Phone	217 999-4751
Certificate Type	Certificate for Provider-Performed Microscopy Procedures (PPMP)
Certificate Type Description	This certificate is issued to a laboratory in which a physician, midlevel practitioner or dentist performs no tests other than the microscopy procedures. This certificate permits the laboratory to also perform waived tests.
Certificate Effective Date	1/1/2025
Certificate Expiration Date	12/31/2026
Facility Type	Physician Office
Lab Director	BRUCE WEBER M D

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