14D1004088 CLIA NUMBER - MARYVILLE DIALYSIS

Laboratory Demographics

  • CLIA Code: 14D1004088
  • Facility Name: MARYVILLE DIALYSIS
  • Facility Address: 2102 VADALABENE DR, STE 1
    MARYVILLE, IL
    ZIP 62062
  • Facility Phone: 618 288-0703
  • Facility Type: End Stage Renal Disease Dialysis Facility
  • Facility Type: Waiver
  • Lab Director: HENRY EDWARD PURCELL MD
  • NPI Number: 1831840180
  • Taxonomy: 261QR0200X - Clinic/Center

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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
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 9/18/2024
Certificate Expiration Date 9/17/2026
Facility Type End Stage Renal Disease Dialysis Facility
Lab Director HENRY EDWARD PURCELL MD

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