23D2067097 CLIA NUMBER - MICHIGAN ENDOSCOPY CENTER AT PROVIDENCE PARK

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Laboratory Demographics

CLIA Number: 23D2067097

Facility Name: MICHIGAN ENDOSCOPY CENTER AT PROVIDENCE PARK

Facility Address:
47601 GRAND RIVER AVE, STE D-110
NOVI, MI
ZIP 48374
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Facility Phone Number: 248 865-6555

Facility Type: Ambulatory Surgery Center

Certificate Type: Waiver

NPI Number: 1629075106

Taxonomy: 261QA1903X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	23D2067097
LAB Type	Ambulatory Surgery Center
Facility Name	MICHIGAN ENDOSCOPY CENTER AT PROVIDENCE PARK
Street	47601 GRAND RIVER AVE, STE D-110
City	NOVI
State	MI
ZIP	48374
Phone	248 865-6555
CertificateType	4
CertificateEffectiveDate	10/9/2023
CertificateExpirationDate	10/8/2025
FacilityType	Waiver

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