36D2102090 CLIA NUMBER - SHADYSIDE CLINIC LLC

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Laboratory Demographics

CLIA Number: 36D2102090

Facility Name: SHADYSIDE CLINIC LLC

Facility Address:
3948 CENTRAL AVE
SHADYSIDE, OH
ZIP 43947
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Facility Phone Number: 740 298-2475

Facility Type: Practitioner Other

Certificate Type: Waiver

NPI Number: 1093183204

Taxonomy: 261QP2300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	36D2102090
LAB Type	Practitioner Other
Facility Name	SHADYSIDE CLINIC LLC
Street	3948 CENTRAL AVE
City	SHADYSIDE
State	OH
ZIP	43947
Phone	740 298-2475
CertificateType	4
CertificateEffectiveDate	9/16/2023
CertificateExpirationDate	9/15/2025
FacilityType	Waiver

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