46D1036105 CLIA NUMBER - PROVO CARE CENTER

Laboratory Demographics

CLIA Number: 46D1036105

Facility Name: PROVO CARE CENTER

Facility Address:
256 E CENTER STR
PROVO, UT
ZIP 84606
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Facility Phone Number: 801 373-8771

Facility Type: Intermediate Care Facility for Mentally Retarded

Certificate Type: Waiver

NPI Number: 1053781054

Taxonomy: 320600000X - Residential Treatment Facility, Intellectual and/or Developmental Disabilities
A residential facility that provides habilitation services and other care and treatment to adults or children diagnosed with developmental and intellectual disabilities and are not able to live independently.

CLIA Record

Field Name	Field Value
CLIA Number	46D1036105
LAB Type	Intermediate Care Facility for Mentally Retarded
Facility Name	PROVO CARE CENTER
Street	256 E CENTER STR
City	PROVO
State	UT
ZIP	84606
Phone	801 373-8771
CertificateType	4
CertificateEffectiveDate	1/20/2023
CertificateExpirationDate	1/19/2025
FacilityType	Waiver

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