05D0723119 CLIA NUMBER - SHELTER ISLAND MEDICAL GROUP INC

Laboratory Demographics

CLIA Number: 05D0723119

Facility Name: SHELTER ISLAND MEDICAL GROUP INC

Facility Address:
1370 ROSECRANS ST STE A
SAN DIEGO, CA
ZIP 92106
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Facility Phone Number: 619 223-2668

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1790886216

Taxonomy: 261QM1300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	05D0723119
LAB Type	Physician Office
Facility Name	SHELTER ISLAND MEDICAL GROUP INC
Street	1370 ROSECRANS ST STE A
City	SAN DIEGO
State	CA
ZIP	92106
Phone	619 223-2668
CertificateType	4
CertificateEffectiveDate	1/1/2023
CertificateExpirationDate	12/31/2024
FacilityType	Waiver

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