52D2212447 CLIA NUMBER - BLANDINE HOUSE INC

Laboratory Demographics

CLIA Number: 52D2212447

Facility Name: BLANDINE HOUSE INC

Facility Address:
25 N PARK AVE
FOND DU LAC, WI
ZIP 54935
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Facility Phone Number: 920 922-9487

Facility Type: Other - SUBSTANCE ABUST TX

Certificate Type: Waiver

NPI Number: 1285922971

Taxonomy: 324500000X - Substance Abuse Rehabilitation Facility
A facility or distinct part of a facility that provides a 24 hr therapeutically planned living and rehabilitative intervention environment for the treatment of individuals with disorders in the abuse of drugs, alcohol, and other substances.

CLIA Record

Field Name	Field Value
CLIA Number	52D2212447
LAB Type	Other - SUBSTANCE ABUST TX
Facility Name	BLANDINE HOUSE INC
Street	25 N PARK AVE
City	FOND DU LAC
State	WI
ZIP	54935
Phone	920 922-9487
CertificateType	4
CertificateEffectiveDate	2/4/2023
CertificateExpirationDate	2/3/2025
FacilityType	Waiver

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