14D2124657 CLIA NUMBER - CHESTNUT FAMILY HEALTH CENTER 702

Laboratory Demographics

CLIA Number: 14D2124657

Facility Name: CHESTNUT FAMILY HEALTH CENTER 702

Facility Address:
702 W CHESTNUT ST
BLOOMINGTON, IL
ZIP 61701
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Facility Phone Number: 618 512-1854

Facility Type: Federally Qualified Health Center

Certificate Type: Waiver

NPI Number: 1447854427

Taxonomy: 261QF0400X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	14D2124657
LAB Type	Federally Qualified Health Center
Facility Name	CHESTNUT FAMILY HEALTH CENTER 702
Street	702 W CHESTNUT ST
City	BLOOMINGTON
State	IL
ZIP	61701
Phone	618 512-1854
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