14D1004088 CLIA NUMBER - MARYVILLE DIALYSIS

Laboratory Demographics

CLIA Number: 14D1004088

Facility Name: MARYVILLE DIALYSIS

Facility Address:
2102 VADALABENE DR, STE 1
MARYVILLE, IL
ZIP 62062
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Facility Phone Number: 618 288-0703

Facility Type: End Stage Renal Disease Dialysis Facility

Certificate Type: Waiver

NPI Number: 1831840180

Taxonomy: 261QR0200X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	14D1004088
LAB Type	End Stage Renal Disease Dialysis Facility
Facility Name	MARYVILLE DIALYSIS
Street	2102 VADALABENE DR, STE 1
City	MARYVILLE
State	IL
ZIP	62062
Phone	618 288-0703
CertificateType	4
CertificateEffectiveDate	9/18/2022
CertificateExpirationDate	9/17/2024
FacilityType	Waiver

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