14D2135472 CLIA NUMBER - PARK MANOR DIALYSIS

Laboratory Demographics

CLIA Number: 14D2135472

Facility Name: PARK MANOR DIALYSIS

Facility Address:
9505 S COLFAX AVE
CHICAGO, IL
ZIP 60617
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Facility Phone Number: 773 978-5237

Facility Type: End Stage Renal Disease Dialysis Facility

Certificate Type: Waiver

NPI Number: 1548791163

Taxonomy: 261QE0700X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	14D2135472
LAB Type	End Stage Renal Disease Dialysis Facility
Facility Name	PARK MANOR DIALYSIS
Street	9505 S COLFAX AVE
City	CHICAGO
State	IL
ZIP	60617
Phone	773 978-5237
CertificateType	4
CertificateEffectiveDate	8/22/2023
CertificateExpirationDate	8/21/2025
FacilityType	Waiver

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