05D0699587 CLIA NUMBER - VILLA AMISTAD

Laboratory Demographics

  • CLIA Code: 05D0699587
  • Facility Name: VILLA AMISTAD
  • Facility Address: 628 O'MEARA ST
    SAN DIEGO, CA
    ZIP 92114
  • Facility Phone: 619 266-2812
  • Facility Type: Intermediate Care Facility for Mentally Retarded
  • Facility Type: Waiver
  • Lab Director: LEON KELLEY
  • NPI Number: 1427274810
  • Taxonomy: 313M00000X - Nursing Facility/Intermediate Care Facility

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CLIA Record

Field Name Field Value
CLIA Number 05D0699587
LAB Type Intermediate Care Facility for Mentally Retarded
Facility Name VILLA AMISTAD
Street 628 O'MEARA ST
City SAN DIEGO
State CA
ZIP 92114
Phone 619 266-2812
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 9/1/2024
Certificate Expiration Date 8/31/2026
Facility Type Intermediate Care Facility for Mentally Retarded
Lab Director LEON KELLEY

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