52D2112696 CLIA NUMBER - PREMISE HEALTH OF WISCONSIN MEDICAL, SC

Laboratory Demographics

CLIA Number: 52D2112696

Facility Name: PREMISE HEALTH OF WISCONSIN MEDICAL, SC

Facility Address:
5910 MINERAL POINT RD
MADISON, WI
ZIP 53705
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Facility Phone Number: 319 304-4863

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1154074326

Taxonomy: 261QM1300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	52D2112696
LAB Type	Physician Office
Facility Name	PREMISE HEALTH OF WISCONSIN MEDICAL, SC
Street	5910 MINERAL POINT RD
City	MADISON
State	WI
ZIP	53705
Phone	319 304-4863
CertificateType	4
CertificateEffectiveDate	5/5/2024
CertificateExpirationDate	5/4/2026
FacilityType	Waiver

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