24D1042493 CLIA NUMBER - PHOENIX RESIDENCE DOUGLAS

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Field Name	Field Value
CLIA Number	24D1042493
LAB Type	Intermediate Care Facility for Mentally Retarded
Facility Name	PHOENIX RESIDENCE DOUGLAS
Street	1538 POINT DOUGLAS ROAD
City	SAINT PAUL
State	MN
ZIP	55119
Phone	651 739-6930
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