05D0573754 CLIA NUMBER - SAN MANUEL INDIAN HEALTH LABORATORY

Laboratory Demographics

CLIA Code: 05D0573754
Facility Name: SAN MANUEL INDIAN HEALTH LABORATORY
Facility Address: 11980 MOUNT VERNON AVE
GRAND TERRACE, CA
ZIP 92313
Facility Phone: 800 732-8805
Facility Type: Federally Qualified Health Center
Facility Type: Waiver
Lab Director: DR. PHILIP T. FARABAUGH
NPI Number: 1174724637
Taxonomy: 332800000X - Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy

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CLIA Record

Field Name	Field Value
CLIA Number	05D0573754
LAB Type	Federally Qualified Health Center
Facility Name	SAN MANUEL INDIAN HEALTH LABORATORY
Street	11980 MOUNT VERNON AVE
City	GRAND TERRACE
State	CA
ZIP	92313
Phone	800 732-8805
Certificate Type	Certificate of Waiver
Certificate Type Description	This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date	3/1/2025
Certificate Expiration Date	2/28/2027
Facility Type	Federally Qualified Health Center
Lab Director	DR. PHILIP T. FARABAUGH

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This page was last updated on: 6/4/2025