23D1058632 CLIA NUMBER - SIXTY FOURTH STREET LLC

Laboratory Demographics

CLIA Number: 23D1058632

Facility Name: SIXTY FOURTH STREET LLC

Facility Address:
2373 64TH STREET SUITE 2200
BYRON CENTER, MI
ZIP 49315
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Facility Phone Number: 616 685-3975

Facility Type: Ambulatory Surgery Center

Certificate Type: Waiver

NPI Number: 1164538286

Taxonomy: 261QA1903X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	23D1058632
LAB Type	Ambulatory Surgery Center
Facility Name	SIXTY FOURTH STREET LLC
Street	2373 64TH STREET SUITE 2200
City	BYRON CENTER
State	MI
ZIP	49315
Phone	616 685-3975
CertificateType	4
CertificateEffectiveDate	9/11/2022
CertificateExpirationDate	9/10/2024
FacilityType	Waiver

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