14D1013305 CLIA NUMBER - MT VERNON CBOC

Laboratory Demographics

  • CLIA Code: 14D1013305
  • Facility Name: MT VERNON CBOC
  • Facility Address: 4100 S WATERTOWER PLACE
    MOUNT VERNON, IL
    ZIP 62864
  • Facility Phone: 618 246-2910
  • Facility Type: Community Clinic
  • Facility Type: Accreditation
  • Lab Director: DON R. DOMENICO
  • NPI Number: 1215141916
  • Taxonomy: 207Q00000X - Family Medicine

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CLIA Record

Field Name Field Value
CLIA Number 14D1013305
LAB Type Community Clinic
Facility Name MT VERNON CBOC
Street 4100 S WATERTOWER PLACE
City MOUNT VERNON
State IL
ZIP 62864
Phone 618 246-2910
Certificate Type Certificate of Accreditation
Certificate Type Description This is a certificate that is issued to a laboratory on the basis of the laboratory's accreditation by an accreditation organization approved by CMS.
Certificate Effective Date 6/6/2003
Certificate Expiration Date 5/22/2026
Facility Type Community Clinic
Lab Director DON R. DOMENICO

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This page was last updated on: 3/20/2025