15D2149269 CLIA NUMBER - PREMISE HEALTH OF INDIANA MEDICAL, PC

Laboratory Demographics

CLIA Number: 15D2149269

Facility Name: PREMISE HEALTH OF INDIANA MEDICAL, PC

Facility Address:
3765 STATE HWY 3
NORTH VERNON, IN
ZIP 47265
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Facility Phone Number: 812 718-4171

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1922771906

Taxonomy: 261QM1300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	15D2149269
LAB Type	Physician Office
Facility Name	PREMISE HEALTH OF INDIANA MEDICAL, PC
Street	3765 STATE HWY 3
City	NORTH VERNON
State	IN
ZIP	47265
Phone	812 718-4171
CertificateType	4
CertificateEffectiveDate	5/30/2022
CertificateExpirationDate	5/29/2024
FacilityType	Waiver

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