05D0573754 CLIA NUMBER - SAN MANUEL INDIAN HEALTH LABORATORY

Laboratory Demographics

CLIA Number: 05D0573754

Facility Name: SAN MANUEL INDIAN HEALTH LABORATORY

Facility Address:
11980 MOUNT VERNON AVE
GRAND TERRACE, CA
ZIP 92313
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Facility Phone Number: (909) 864-1097

Facility Type: FEDERALLY QUALIFIED HEALTH CENTER

Certificate Type: Accreditation

NPI Number: 1174724637

Taxonomy: 332800000X - Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
An Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy means a pharmacy operated by the Indian Health Service, an Indian tribe or tribal organization, or an urban Indian organization, all of which are defined in Section 4 of the Indian Health Care Improvement Act, 25 U.S.C. 1603.

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	(909) 864-1097

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This page was last updated on: 1/7/2022