14D2136480 CLIA NUMBER - CRYSTAL CLEAR MOBILE PROVIDERS

Laboratory Demographics

CLIA Number: 14D2136480

Facility Name: CRYSTAL CLEAR MOBILE PROVIDERS

Facility Address:
423 N HIGH ST
BELLEVILLE, IL
ZIP 62220
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Facility Phone Number: 618 416-7738

Facility Type: Practitioner Other

Certificate Type: Waiver

NPI Number: 1619409075

Taxonomy: 261QP2300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	14D2136480
LAB Type	Practitioner Other
Facility Name	CRYSTAL CLEAR MOBILE PROVIDERS
Street	423 N HIGH ST
City	BELLEVILLE
State	IL
ZIP	62220
Phone	618 416-7738
CertificateType	4
CertificateEffectiveDate	9/11/2023
CertificateExpirationDate	9/10/2025
FacilityType	Waiver

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