05D0896113 CLIA NUMBER - CASA DE VIDA

Laboratory Demographics

  • CLIA Code: 05D0896113
  • Facility Name: CASA DE VIDA
  • Facility Address: 879 MEINECKE AVE
    SAN LUIS OBISPO, CA
    ZIP 93405
  • Facility Phone: 805 544-5332
  • Facility Type: Intermediate Care Facility for Mentally Retarded
  • Facility Type: Waiver
  • Lab Director: DANIEL J. KINGMA
  • NPI Number: 1689889131
  • Taxonomy: 310500000X - Intermediate Care Facility, Mental Illness

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CLIA Record

Field Name Field Value
CLIA Number 05D0896113
LAB Type Intermediate Care Facility for Mentally Retarded
Facility Name CASA DE VIDA
Street 879 MEINECKE AVE
City SAN LUIS OBISPO
State CA
ZIP 93405
Phone 805 544-5332
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 12/30/2024
Certificate Expiration Date 12/29/2026
Facility Type Intermediate Care Facility for Mentally Retarded
Lab Director DANIEL J. KINGMA

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