52D2161005 CLIA NUMBER - SOUTHERN LAKES ENDOSCOPY CENTER, LLC

Laboratory Demographics

CLIA Number: 52D2161005

Facility Name: SOUTHERN LAKES ENDOSCOPY CENTER, LLC

Facility Address:
240 MAPLE AVENUE SUITE 2220
MUKWONAGO, WI
ZIP 53149
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Facility Phone Number: 414 454-0600

Facility Type: Ambulatory Surgery Center

Certificate Type: Waiver

NPI Number: 1851887715

Taxonomy: 261QA1903X - Clinic/Center

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
CertificateType	4
CertificateEffectiveDate	1/24/2023
CertificateExpirationDate	1/23/2025
FacilityType	Waiver

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