14D2052961 CLIA NUMBER - ASHLAND AVENUE G I, S C

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Laboratory Demographics

CLIA Number: 14D2052961

Facility Name: ASHLAND AVENUE G I, S C

Facility Address:
3004 N ASHLAND AVE
CHICAGO, IL
ZIP 60657
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Facility Phone Number: 773 871-4600

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1962781252

Taxonomy: 261QE0800X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	14D2052961
LAB Type	Physician Office
Facility Name	ASHLAND AVENUE G I, S C
Street	3004 N ASHLAND AVE
City	CHICAGO
State	IL
ZIP	60657
Phone	773 871-4600
CertificateType	4
CertificateEffectiveDate	1/23/2023
CertificateExpirationDate	1/22/2025
FacilityType	Waiver

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