05D0889614 CLIA NUMBER - WILSON GOMER, MD PROFESSIONAL MEDICAL CORP

Laboratory Demographics

CLIA Number: 05D0889614

Facility Name: WILSON GOMER, MD PROFESSIONAL MEDICAL CORP

Facility Address:
1800 NORTH WESTERN AVENUE SUITE 103
SAN BERNARDINO, CA
ZIP 92411
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Facility Phone Number: 909 887-7427

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1104327543

Taxonomy: 261QH0100X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	05D0889614
LAB Type	Physician Office
Facility Name	WILSON GOMER, MD PROFESSIONAL MEDICAL CORP
Street	1800 NORTH WESTERN AVENUE SUITE 103
City	SAN BERNARDINO
State	CA
ZIP	92411
Phone	909 887-7427
CertificateType	4
CertificateEffectiveDate	8/1/2022
CertificateExpirationDate	7/31/2024
FacilityType	Waiver

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