25D1043490 CLIA NUMBER - MISSISSIPPI ADOLESCENT CENTER

Laboratory Demographics

CLIA Code: 25D1043490
Facility Name: MISSISSIPPI ADOLESCENT CENTER
Facility Address: 760 BROOKMAN DRIVE
BROOKHAVEN, MS
ZIP 39601
Facility Phone: 601 823-5700
Facility Type: Intermediate Care Facility for Mentally Retarded
Facility Type: Waiver
Lab Director: CLINT ASHLEY
NPI Number: 1376840058
Taxonomy: 320600000X - Residential Treatment Facility, Intellectual and/or Developmental Disabilities

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CLIA Record

Field Name	Field Value
CLIA Number	25D1043490
LAB Type	Intermediate Care Facility for Mentally Retarded
Facility Name	MISSISSIPPI ADOLESCENT CENTER
Street	760 BROOKMAN DRIVE
City	BROOKHAVEN
State	MS
ZIP	39601
Phone	601 823-5700
Certificate Type	Certificate of Waiver
Certificate Type Description	This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date	7/26/2025
Certificate Expiration Date	7/25/2027
Facility Type	Intermediate Care Facility for Mentally Retarded
Lab Director	CLINT ASHLEY

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