14D1079104 CLIA NUMBER - GRAND AVENUE SURGICAL CENTER

Laboratory Demographics

CLIA Number: 14D1079104

Facility Name: GRAND AVENUE SURGICAL CENTER

Facility Address:
17 W GRAND AVE
CHICAGO, IL
ZIP 60654
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Facility Phone Number: 312 222-5610

Facility Type: Ambulatory Surgery Center

Certificate Type: Waiver

NPI Number: 1144482290

Taxonomy: 261QA1903X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	14D1079104
LAB Type	Ambulatory Surgery Center
Facility Name	GRAND AVENUE SURGICAL CENTER
Street	17 W GRAND AVE
City	CHICAGO
State	IL
ZIP	60654
Phone	312 222-5610
CertificateType	4
CertificateEffectiveDate	1/24/2024
CertificateExpirationDate	1/23/2026
FacilityType	Waiver

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