15D2126074 CLIA NUMBER - SUPRO DIRECT

Laboratory Demographics

  • CLIA Code: 15D2126074
  • Facility Name: SUPRO DIRECT
  • Facility Address: 701 E COUNTY LINE RD STE 210
    GREENWOOD, IN
    ZIP 46143
  • Facility Phone: 317 300-7424
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: PRAVEEN RAJANAHALLI
  • NPI Number: 1750829230
  • Taxonomy: 207Q00000X - Family Medicine

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CLIA Record

Field Name Field Value
CLIA Number 15D2126074
LAB Type Physician Office
Facility Name SUPRO DIRECT
Street 701 E COUNTY LINE RD STE 210
City GREENWOOD
State IN
ZIP 46143
Phone 317 300-7424
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 2/20/2025
Certificate Expiration Date 2/19/2027
Facility Type Physician Office
Lab Director PRAVEEN RAJANAHALLI

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