14D1018526 CLIA NUMBER - EVERGREEN CARE CENTER LTD

Laboratory Demographics

CLIA Number: 14D1018526

Facility Name: EVERGREEN CARE CENTER LTD

Facility Address:
9760 S KEDZIE AVE-SUITE 3
EVERGREEN PARK, IL
ZIP 60805
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Facility Phone Number: 708 423-6209

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1447449616

Taxonomy: 208D00000X - General Practice
A physician who specializes in the general practice of diagnosing, treating, and managing patients with a variety of illnesses and conditions. Source: National Uniform Claim Committee

CLIA Record

Field Name	Field Value
CLIA Number	14D1018526
LAB Type	Physician Office
Facility Name	EVERGREEN CARE CENTER LTD
Street	9760 S KEDZIE AVE-SUITE 3
City	EVERGREEN PARK
State	IL
ZIP	60805
Phone	708 423-6209
CertificateType	4
CertificateEffectiveDate	10/24/2023
CertificateExpirationDate	10/23/2025
FacilityType	Waiver

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