14D2208683 CLIA NUMBER - SOUTHERN THIRTY ADOLESCENT CENTER

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Laboratory Demographics

CLIA Number: 14D2208683

Facility Name: SOUTHERN THIRTY ADOLESCENT CENTER

Facility Address:
17077 N HWY 37
MOUNT VERNON, IL
ZIP 62864
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Facility Phone Number: 618 242-2238

Facility Type: Other - SHELTER FOR DCFS YOUTH

Certificate Type: Waiver

NPI Number: 1720199748

Taxonomy: 332B00000X - Durable Medical Equipment & Medical Supplies
A supplier of medical equipment such as respirators, wheelchairs, home dialysis systems, or monitoring systems, that are prescribed by a physician for a patient's use in the home and that are usable for an extended period of time.

CLIA Record

Field Name	Field Value
CLIA Number	14D2208683
LAB Type	Other - SHELTER FOR DCFS YOUTH
Facility Name	SOUTHERN THIRTY ADOLESCENT CENTER
Street	17077 N HWY 37
City	MOUNT VERNON
State	IL
ZIP	62864
Phone	618 242-2238
CertificateType	4
CertificateEffectiveDate	1/7/2023
CertificateExpirationDate	1/6/2025
FacilityType	Waiver

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