24D2196134 CLIA NUMBER - DIVINE HOUSE, INC

Laboratory Demographics

CLIA Code: 24D2196134
Facility Name: DIVINE HOUSE, INC
Facility Address: 1132 28TH AVE S STE 105A
MOORHEAD, MN
ZIP 56560
Facility Phone: 320 231-2738
Facility Type: Other - HCBS
Facility Type: Waiver
Lab Director: DEBRA J. SHRIVER
NPI Number: 1720166259
Taxonomy: 320900000X - Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities

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CLIA Record

Field Name	Field Value
CLIA Number	24D2196134
LAB Type	Other - HCBS
Facility Name	DIVINE HOUSE, INC
Street	1132 28TH AVE S STE 105A
City	MOORHEAD
State	MN
ZIP	56560
Phone	320 231-2738
Certificate Type	Certificate of Waiver
Certificate Type Description	This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date	10/15/2024
Certificate Expiration Date	10/14/2026
Facility Type	Other - HCBS
Lab Director	DEBRA J. SHRIVER

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