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14D2265598 CLIA NUMBER - PREMISE HEALTH OF ILLINOIS MEDICAL, S C

Laboratory Demographics

CLIA Number: 14D2265598

Facility Name: PREMISE HEALTH OF ILLINOIS MEDICAL, S C

Facility Address:
4179 DUNDEE RD - STE A106
NORTHBROOK, IL
ZIP 60062
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Facility Phone Number: 847 402-2300

Facility Type: Physician Office

Certificate Type: Waiver
NPI Number: 1629716121

Taxonomy: 261QM1300X - Clinic/Center

CLIA Record

Field Name Field Value
CLIA Number 14D2265598
LAB Type Physician Office
Facility Name PREMISE HEALTH OF ILLINOIS MEDICAL, S C
Street 4179 DUNDEE RD - STE A106
City NORTHBROOK
State IL
ZIP 60062
Phone 847 402-2300
CertificateType 4
CertificateEffectiveDate 7/29/2022
CertificateExpirationDate 7/28/2024
FacilityType Waiver

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