14D2199409 CLIA NUMBER - ACTIVATE BY EVERSIDE - SPRINGFIELD CLINIC

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Laboratory Demographics

CLIA Number: 14D2199409

Facility Name: ACTIVATE BY EVERSIDE - SPRINGFIELD CLINIC

Facility Address:
2930 MONTVALE, SUITE C
SPRINGFIELD, IL
ZIP 62704
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Facility Phone Number: 217 280-5254

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1518424167

Taxonomy: 261QP2300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	14D2199409
LAB Type	Physician Office
Facility Name	ACTIVATE BY EVERSIDE - SPRINGFIELD CLINIC
Street	2930 MONTVALE, SUITE C
City	SPRINGFIELD
State	IL
ZIP	62704
Phone	217 280-5254
CertificateType	4
CertificateEffectiveDate	11/9/2022
CertificateExpirationDate	11/8/2024
FacilityType	Waiver

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