05D1019730 CLIA NUMBER - PACIFIC HOME CARE

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Laboratory Demographics

CLIA Number: 05D1019730

Facility Name: PACIFIC HOME CARE

Facility Address:
254 EAST 228TH ST
CARSON, CA
ZIP 90745
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Facility Phone Number: 310 518-5178

Facility Type: Intermediate Care Facility for Mentally Retarded

Certificate Type: Waiver

NPI Number: 1164663746

Taxonomy: 320600000X - Residential Treatment Facility, Intellectual and/or Developmental Disabilities
A residential facility that provides habilitation services and other care and treatment to adults or children diagnosed with developmental and intellectual disabilities and are not able to live independently.

CLIA Record

Field Name	Field Value
CLIA Number	05D1019730
LAB Type	Intermediate Care Facility for Mentally Retarded
Facility Name	PACIFIC HOME CARE
Street	254 EAST 228TH ST
City	CARSON
State	CA
ZIP	90745
Phone	310 518-5178
CertificateType	4
CertificateEffectiveDate	7/28/2022
CertificateExpirationDate	7/27/2024
FacilityType	Waiver

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