23D2135943 CLIA NUMBER - MED SPORTS VANTAGE, PLLC

Laboratory Demographics

CLIA Number: 23D2135943

Facility Name: MED SPORTS VANTAGE, PLLC

Facility Address:
210 S EAST STREET SUITE 2
BRIGHTON, MI
ZIP 48116
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Facility Phone Number: 810 626-3036

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1326587114

Taxonomy: 261QP2300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	23D2135943
LAB Type	Physician Office
Facility Name	MED SPORTS VANTAGE, PLLC
Street	210 S EAST STREET SUITE 2
City	BRIGHTON
State	MI
ZIP	48116
Phone	810 626-3036
CertificateType	4
CertificateEffectiveDate	8/30/2023
CertificateExpirationDate	8/29/2025
FacilityType	Waiver

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