05D0572174 CLIA NUMBER - ADOLESCENTS, BABIES & CHILDREN PEDIATRIC MED GROUP

Laboratory Demographics

CLIA Number: 05D0572174

Facility Name: ADOLESCENTS, BABIES & CHILDREN PEDIATRIC MED GROUP

Facility Address:
702 WAKE AVENUE AVE
EL CENTRO, CA
ZIP 92243
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Facility Phone Number: 760 352-7216

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1497275291

Taxonomy: 261QM0801X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	05D0572174
LAB Type	Physician Office
Facility Name	ADOLESCENTS, BABIES & CHILDREN PEDIATRIC MED GROUP
Street	702 WAKE AVENUE AVE
City	EL CENTRO
State	CA
ZIP	92243
Phone	760 352-7216
CertificateType	4
CertificateEffectiveDate	9/1/2022
CertificateExpirationDate	8/31/2024
FacilityType	Waiver

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