14D2051627 CLIA NUMBER - PREMISE HEALTH OF ILLINOIS MEDICAL, SC

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Laboratory Demographics

CLIA Number: 14D2051627

Facility Name: PREMISE HEALTH OF ILLINOIS MEDICAL, SC

Facility Address:
AT UNITED AIRLINES HEALTH CLINIC, TERMINAL 2, LL 11601 W TOUHY AVE
CHICAGO, IL
ZIP 60666
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Facility Phone Number: 773 601-2525

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1235584475

Taxonomy: 261QM1300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	14D2051627
LAB Type	Physician Office
Facility Name	PREMISE HEALTH OF ILLINOIS MEDICAL, SC
Street	AT UNITED AIRLINES HEALTH CLINIC, TERMINAL 2, LL 11601 W TOUHY AVE
City	CHICAGO
State	IL
ZIP	60666
Phone	773 601-2525
CertificateType	4
CertificateEffectiveDate	12/21/2022
CertificateExpirationDate	12/20/2024
FacilityType	Waiver

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