03D1093134 CLIA NUMBER - SAN JOSE INTEGRATED CLINIC LLC

Laboratory Demographics

  • CLIA Code: 03D1093134
  • Facility Name: SAN JOSE INTEGRATED CLINIC LLC
  • Facility Address: 1233 N MAIN ST STE 10
    SAN LUIS, AZ
    ZIP 85349
  • Facility Phone: 928 722-6098
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: CLARISSE NGUENA-NANA
  • NPI Number: 1770753162
  • Taxonomy: 207Q00000X - Family Medicine

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CLIA Record

Field Name Field Value
CLIA Number 03D1093134
LAB Type Physician Office
Facility Name SAN JOSE INTEGRATED CLINIC LLC
Street 1233 N MAIN ST STE 10
City SAN LUIS
State AZ
ZIP 85349
Phone 928 722-6098
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 12/11/2024
Certificate Expiration Date 12/10/2026
Facility Type Physician Office
Lab Director CLARISSE NGUENA-NANA

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