03D1093775 CLIA NUMBER - PROVIDENCE PEDIATRICS, CORP

Laboratory Demographics

  • CLIA Code: 03D1093775
  • Facility Name: PROVIDENCE PEDIATRICS, CORP
  • Facility Address: 1701 W GLENDALE AVE, STE 3
    PHOENIX, AZ
    ZIP 85021
  • Facility Phone: 602 246-9090
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: GERARDO SICALO-OBORSKY, MD
  • NPI Number: 1508180043
  • Taxonomy: 261QM2500X - Clinic/Center

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CLIA Record

Field Name Field Value
CLIA Number 03D1093775
LAB Type Physician Office
Facility Name PROVIDENCE PEDIATRICS, CORP
Street 1701 W GLENDALE AVE, STE 3
City PHOENIX
State AZ
ZIP 85021
Phone 602 246-9090
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 12/31/2024
Certificate Expiration Date 12/30/2026
Facility Type Physician Office
Lab Director GERARDO SICALO-OBORSKY, MD

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