52D0879904 CLIA NUMBER - SOUTHERN WISCONSIN CENTER

Laboratory Demographics

CLIA Number: 52D0879904

Facility Name: SOUTHERN WISCONSIN CENTER

Facility Address:
21425 SPRING ST
UNION GROVE, WI
ZIP 53182
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Facility Phone Number: 262 878-2411

Facility Type: Intermediate Care Facility for Mentally Retarded

Certificate Type: Waiver

NPI Number: 1043326747

Taxonomy: 315P00000X - Intermediate Care Facility, Intellectual Disabilities
An intermediate care facility providing services for individuals with intellectual disabilities.

CLIA Record

Field Name	Field Value
CLIA Number	52D0879904
LAB Type	Intermediate Care Facility for Mentally Retarded
Facility Name	SOUTHERN WISCONSIN CENTER
Street	21425 SPRING ST
City	UNION GROVE
State	WI
ZIP	53182
Phone	262 878-2411
CertificateType	4
CertificateEffectiveDate	12/3/2023
CertificateExpirationDate	12/2/2025
FacilityType	Waiver

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