14D0963523 CLIA NUMBER - SPRINGFIELD MONTVALE DIALYSIS

Laboratory Demographics

CLIA Number: 14D0963523

Facility Name: SPRINGFIELD MONTVALE DIALYSIS

Facility Address:
2930 S MONTVALE DRIVE SUITE A
SPRINGFIELD, IL
ZIP 62704
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Facility Phone Number: 217 793-2781

Facility Type: End Stage Renal Disease Dialysis Facility

Certificate Type: Waiver

NPI Number: 1518926781

Taxonomy: 261QE0700X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	14D0963523
LAB Type	End Stage Renal Disease Dialysis Facility
Facility Name	SPRINGFIELD MONTVALE DIALYSIS
Street	2930 S MONTVALE DRIVE SUITE A
City	SPRINGFIELD
State	IL
ZIP	62704
Phone	217 793-2781
CertificateType	4
CertificateEffectiveDate	7/30/2023
CertificateExpirationDate	7/29/2025
FacilityType	Waiver

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