14D1054852 CLIA NUMBER - NORTHWEST AMBUCARE

Laboratory Demographics

CLIA Number: 14D1054852

Facility Name: NORTHWEST AMBUCARE

Facility Address:
4040 W PETERSON AVE
CHICAGO, IL
ZIP 60646
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Facility Phone Number: 773 267-0554

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1811965635

Taxonomy: 261QP1100X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	14D1054852
LAB Type	Physician Office
Facility Name	NORTHWEST AMBUCARE
Street	4040 W PETERSON AVE
City	CHICAGO
State	IL
ZIP	60646
Phone	773 267-0554
CertificateType	4
CertificateEffectiveDate	6/1/2022
CertificateExpirationDate	5/31/2024
FacilityType	Waiver

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