14D2156478 CLIA NUMBER - WELL-ROOTED PEDIATRICS L L C

Laboratory Demographics

CLIA Number: 14D2156478

Facility Name: WELL-ROOTED PEDIATRICS L L C

Facility Address:
390 E CONGRESS PKWY - STE I
CRYSTAL LAKE, IL
ZIP 60014
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Facility Phone Number: 815 355-1605

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1780157602

Taxonomy: 363LF0000X - Nurse Practitioner

CLIA Record

Field Name	Field Value
CLIA Number	14D2156478
LAB Type	Physician Office
Facility Name	WELL-ROOTED PEDIATRICS L L C
Street	390 E CONGRESS PKWY - STE I
City	CRYSTAL LAKE
State	IL
ZIP	60014
Phone	815 355-1605
CertificateType	4
CertificateEffectiveDate	10/18/2022
CertificateExpirationDate	10/17/2024
FacilityType	Waiver

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