14D2270655 CLIA NUMBER - DEACONESS ILLINOIS CLINIC EXPRESS DEACONESS ILLINOIS SPECIALTY CLINIC, INC

Laboratory Demographics

  • CLIA Code: 14D2270655
  • Facility Name: DEACONESS ILLINOIS CLINIC EXPRESS DEACONESS ILLINOIS SPECIALTY CLINIC, INC
  • Facility Address: 3111 BROADWAY ST
    MOUNT VERNON, IL
    ZIP 62864
  • Facility Phone: 618 241-0300
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: WENDELL W. BECTON
  • NPI Number: 1558088138
  • Taxonomy: 207Q00000X - Family Medicine

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CLIA Record

Field Name Field Value
CLIA Number 14D2270655
LAB Type Physician Office
Facility Name DEACONESS ILLINOIS CLINIC EXPRESS DEACONESS ILLINOIS SPECIALTY CLINIC, INC
Street 3111 BROADWAY ST
City MOUNT VERNON
State IL
ZIP 62864
Phone 618 241-0300
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 10/19/2024
Certificate Expiration Date 10/18/2026
Facility Type Physician Office
Lab Director WENDELL W. BECTON

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This page was last updated on: 9/29/2025