15D0961885 CLIA NUMBER - ELLETTSVILLE FAMILY PRACTICE DBA IU HLTH SIP ELLETTSVILLE

Laboratory Demographics

CLIA Number: 15D0961885

Facility Name: ELLETTSVILLE FAMILY PRACTICE DBA IU HLTH SIP ELLETTSVILLE

Facility Address:
5921 W SR 46
BLOOMINGTON, IN
ZIP 47404
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Facility Phone Number: 812 935-8866

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1447589312

Taxonomy: 343900000X - Non-emergency Medical Transport (VAN)
A land vehicle with a capacity to meet special height, clearance, access, and seating, for the conveyance of persons in non-emergency situations. The vehicle may or may not be required to meet local county or state regulations.

CLIA Record

Field Name	Field Value
CLIA Number	15D0961885
LAB Type	Physician Office
Facility Name	ELLETTSVILLE FAMILY PRACTICE DBA IU HLTH SIP ELLETTSVILLE
Street	5921 W SR 46
City	BLOOMINGTON
State	IN
ZIP	47404
Phone	812 935-8866
CertificateType	4
CertificateEffectiveDate	6/23/2022
CertificateExpirationDate	6/22/2024
FacilityType	Waiver

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