24D2063648 CLIA NUMBER - ESSENTIA HEALTH ST MARY'S - MAHNOMEN CLINIC

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Laboratory Demographics

CLIA Number: 24D2063648

Facility Name: ESSENTIA HEALTH ST MARY'S - MAHNOMEN CLINIC

Facility Address:
117 NORTH MAIN STREET
MAHNOMEN, MN
ZIP 56557
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Facility Phone Number: 701 364-8714

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1750725586

Taxonomy: 261QR1300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	24D2063648
LAB Type	Physician Office
Facility Name	ESSENTIA HEALTH ST MARY'S - MAHNOMEN CLINIC
Street	117 NORTH MAIN STREET
City	MAHNOMEN
State	MN
ZIP	56557
Phone	701 364-8714
CertificateType	4
CertificateEffectiveDate	8/7/2023
CertificateExpirationDate	8/6/2025
FacilityType	Waiver

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