15D2065611 CLIA NUMBER - PROACTIVE MD MADISON HEALTH CENTER

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Laboratory Demographics

CLIA Number: 15D2065611

Facility Name: PROACTIVE MD MADISON HEALTH CENTER

Facility Address:
2580 MICHIGAN RD
MADISON, IN
ZIP 47250
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Facility Phone Number: 812 801-4323

Facility Type: Practitioner Other

Certificate Type: Waiver

NPI Number: 1548713332

Taxonomy: 261QP2300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	15D2065611
LAB Type	Practitioner Other
Facility Name	PROACTIVE MD MADISON HEALTH CENTER
Street	2580 MICHIGAN RD
City	MADISON
State	IN
ZIP	47250
Phone	812 801-4323
CertificateType	4
CertificateEffectiveDate	9/11/2023
CertificateExpirationDate	9/10/2025
FacilityType	Waiver

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