24D1042487 CLIA NUMBER - PHOENIX RESIDENCE LUDDEN

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Field Name	Field Value
CLIA Number	24D1042487
LAB Type	Intermediate Care Facility for Mentally Retarded
Facility Name	PHOENIX RESIDENCE LUDDEN
Street	7177 LONG LAKE ROAD
City	MOUNDS VIEW
State	MN
ZIP	55112
Phone	763 398-3812
Certificate Type	Certificate of Waiver
Certificate Type Description	This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date	4/12/2024
Certificate Expiration Date	4/11/2026
Facility Type	Intermediate Care Facility for Mentally Retarded
Lab Director	KIMBERLY E. HUMAN

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