52D2161005 CLIA NUMBER - SOUTHERN LAKES ENDOSCOPY CENTER, LLC

Laboratory Demographics

  • CLIA Code: 52D2161005
  • Facility Name: SOUTHERN LAKES ENDOSCOPY CENTER, LLC
  • Facility Address: 240 MAPLE AVENUE SUITE 2220
    MUKWONAGO, WI
    ZIP 53149
  • Facility Phone: 414 454-0600
  • Facility Type: Ambulatory Surgery Center
  • Facility Type: Waiver
  • Lab Director: DR. WILLIAM J. BLOSKY
  • NPI Number: 1851887715
  • Taxonomy: 261QA1903X - Clinic/Center

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CLIA Record

Field Name Field Value
CLIA Number 52D2161005
LAB Type Ambulatory Surgery Center
Facility Name SOUTHERN LAKES ENDOSCOPY CENTER, LLC
Street 240 MAPLE AVENUE SUITE 2220
City MUKWONAGO
State WI
ZIP 53149
Phone 414 454-0600
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 1/24/2025
Certificate Expiration Date 1/23/2027
Facility Type Ambulatory Surgery Center
Lab Director DR. WILLIAM J. BLOSKY

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