26D2095959 CLIA NUMBER - MIDAMERICA SPINE CENTER LLC

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Laboratory Demographics

CLIA Number: 26D2095959

Facility Name: MIDAMERICA SPINE CENTER LLC

Facility Address:
5139 MATTIS ROAD, SUITE 100
SAINT LOUIS, MO
ZIP 63128
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Facility Phone Number: 636 529-1618

Facility Type: Ambulatory Surgery Center

Certificate Type: Waiver

NPI Number: 1114317757

Taxonomy: 261QA1903X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	26D2095959
LAB Type	Ambulatory Surgery Center
Facility Name	MIDAMERICA SPINE CENTER LLC
Street	5139 MATTIS ROAD, SUITE 100
City	SAINT LOUIS
State	MO
ZIP	63128
Phone	636 529-1618
CertificateType	4
CertificateEffectiveDate	5/13/2023
CertificateExpirationDate	5/12/2025
FacilityType	Waiver

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