14D2277676 CLIA NUMBER - DEACONESS ILLINOIS CLINIC DEACONESS ILLINOIS CLINIC, INC

Laboratory Demographics

  • CLIA Code: 14D2277676
  • Facility Name: DEACONESS ILLINOIS CLINIC DEACONESS ILLINOIS CLINIC, INC
  • Facility Address: 4105 N WATER TOWER PLACE
    MOUNT VERNON, IL
    ZIP 62864
  • Facility Phone: 618 244-9495
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: DENNON W. DAVIS
  • NPI Number: 1063128544
  • Taxonomy: 207Q00000X - Family Medicine

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CLIA Record

Field Name Field Value
CLIA Number 14D2277676
LAB Type Physician Office
Facility Name DEACONESS ILLINOIS CLINIC DEACONESS ILLINOIS CLINIC, INC
Street 4105 N WATER TOWER PLACE
City MOUNT VERNON
State IL
ZIP 62864
Phone 618 244-9495
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 3/2/2025
Certificate Expiration Date 3/1/2027
Facility Type Physician Office
Lab Director DENNON W. DAVIS

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