05D0927628 CLIA NUMBER - FOUNTAIN MEDICAL CLINIC

Laboratory Demographics

  • CLIA Code: 05D0927628
  • Facility Name: FOUNTAIN MEDICAL CLINIC
  • Facility Address: 1155 N VERMONT AVE, STE 202
    LOS ANGELES, CA
    ZIP 90029
  • Facility Phone: 213 913-9094
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: EVELYN C. RIVERO MD
  • NPI Number: 1194767871
  • Taxonomy: 314000000X - Skilled Nursing Facility

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CLIA Record

Field Name Field Value
CLIA Number 05D0927628
LAB Type Physician Office
Facility Name FOUNTAIN MEDICAL CLINIC
Street 1155 N VERMONT AVE, STE 202
City LOS ANGELES
State CA
ZIP 90029
Phone 213 913-9094
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 4/24/2023
Certificate Expiration Date 4/23/2025
Facility Type Physician Office
Lab Director EVELYN C. RIVERO MD

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This page was last updated on: 3/20/2025