15D2144157 CLIA NUMBER - PROACTIVE MD-DPC MAIN

Laboratory Demographics

  • CLIA Code: 15D2144157
  • Facility Name: PROACTIVE MD-DPC MAIN
  • Facility Address: 3487 S 4TH ST
    TERRE HAUTE, IN
    ZIP 47802
  • Facility Phone: 812 220-4755
  • Facility Type: Practitioner Other
  • Facility Type: Waiver
  • Lab Director: MEGAN MARIETTA
  • NPI Number: 1972011815
  • Taxonomy: 261QP2300X - Clinic/Center

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CLIA Record

Field Name Field Value
CLIA Number 15D2144157
LAB Type Practitioner Other
Facility Name PROACTIVE MD-DPC MAIN
Street 3487 S 4TH ST
City TERRE HAUTE
State IN
ZIP 47802
Phone 812 220-4755
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 2/12/2024
Certificate Expiration Date 2/11/2026
Facility Type Practitioner Other
Lab Director MEGAN MARIETTA

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