24D1042487 CLIA NUMBER - PHOENIX RESIDENCE LUDDEN

Laboratory Demographics

CLIA Number: 24D1042487

Facility Name: PHOENIX RESIDENCE LUDDEN

Facility Address:
7177 LONG LAKE ROAD
MOUNDS VIEW, MN
ZIP 55112
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Facility Phone Number: 763 398-3812

Facility Type: Intermediate Care Facility for Mentally Retarded

Certificate Type: Waiver

NPI Number: 1649376005

Taxonomy: 315P00000X - Intermediate Care Facility, Intellectual Disabilities
An intermediate care facility providing services for individuals with intellectual disabilities.

CLIA Record

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
CertificateType	4
CertificateEffectiveDate	4/12/2024
CertificateExpirationDate	4/11/2026
FacilityType	Waiver

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