15D2291036 CLIA NUMBER - CITYBLOCK MEDICAL PRACTICE, PA

Laboratory Demographics

  • CLIA Code: 15D2291036
  • Facility Name: CITYBLOCK MEDICAL PRACTICE, PA
  • Facility Address: 3030 LAKE AVENUE, SUITE 21
    FORT WAYNE, IN
    ZIP 46805
  • Facility Phone: 800 336-1100
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: MICHAEL PERSON
  • NPI Number: 1790447373
  • Taxonomy: 208D00000X - General Practice

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CLIA Record

Field Name Field Value
CLIA Number 15D2291036
LAB Type Physician Office
Facility Name CITYBLOCK MEDICAL PRACTICE, PA
Street 3030 LAKE AVENUE, SUITE 21
City FORT WAYNE
State IN
ZIP 46805
Phone 800 336-1100
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 10/4/2023
Certificate Expiration Date 10/3/2025
Facility Type Physician Office
Lab Director MICHAEL PERSON

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