36D2279116 CLIA NUMBER - FAIRWAY BEHAVIORAL HEALTH, LLC

Laboratory Demographics

  • CLIA Code: 36D2279116
  • Facility Name: FAIRWAY BEHAVIORAL HEALTH, LLC
  • Facility Address: 140 FAIRWAY DR, BOX 2
    WILMINGTON, OH
    ZIP 45177
  • Facility Phone: 937 974-5591
  • Facility Type: Practitioner Other
  • Facility Type: Waiver
  • Lab Director: POLLY VAUGHAN
  • NPI Number: 1780328344
  • Taxonomy: 363LP0808X - Nurse Practitioner

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CLIA Record

Field Name Field Value
CLIA Number 36D2279116
LAB Type Practitioner Other
Facility Name FAIRWAY BEHAVIORAL HEALTH, LLC
Street 140 FAIRWAY DR, BOX 2
City WILMINGTON
State OH
ZIP 45177
Phone 937 974-5591
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 3/29/2025
Certificate Expiration Date 3/28/2027
Facility Type Practitioner Other
Lab Director POLLY VAUGHAN

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