15D2277081 CLIA NUMBER - NWI MDVIP LLC

Laboratory Demographics

  • CLIA Code: 15D2277081
  • Facility Name: NWI MDVIP LLC
  • Facility Address: 9150 E 109TH AVE STE 2B
    CROWN POINT, IN
    ZIP 46307
  • Facility Phone: 219 312-2947
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: BRENT A. JACOBUS
  • NPI Number: 1538877972
  • Taxonomy: 207Q00000X - Family Medicine

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CLIA Record

Field Name Field Value
CLIA Number 15D2277081
LAB Type Physician Office
Facility Name NWI MDVIP LLC
Street 9150 E 109TH AVE STE 2B
City CROWN POINT
State IN
ZIP 46307
Phone 219 312-2947
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 2/22/2025
Certificate Expiration Date 2/21/2027
Facility Type Physician Office
Lab Director BRENT A. JACOBUS

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