24D1042492 CLIA NUMBER - PHOENIX RESIDENCE VIKING

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Field Name	Field Value
CLIA Number	24D1042492
LAB Type	Intermediate Care Facility for Mentally Retarded
Facility Name	PHOENIX RESIDENCE VIKING
Street	645 VIKING DRIVE EAST
City	LITTLE CANADA
State	MN
ZIP	55117
Phone	651 294-2076
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