05D1058226 CLIA NUMBER - OTAY LAKES SURGERY CENTER, LLC

Laboratory Demographics

  • CLIA Code: 05D1058226
  • Facility Name: OTAY LAKES SURGERY CENTER, LLC
  • Facility Address: 955 LANE AVE, SUITE 100
    CHULA VISTA, CA
    ZIP 91914
  • Facility Phone: 619 754-2260
  • Facility Type: Ambulatory Surgery Center
  • Facility Type: Waiver
  • Lab Director: BRYCE KIM
  • NPI Number: 1376595421
  • Taxonomy: 261QA1903X - Clinic/Center

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CLIA Record

Field Name Field Value
CLIA Number 05D1058226
LAB Type Ambulatory Surgery Center
Facility Name OTAY LAKES SURGERY CENTER, LLC
Street 955 LANE AVE, SUITE 100
City CHULA VISTA
State CA
ZIP 91914
Phone 619 754-2260
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 8/31/2024
Certificate Expiration Date 8/30/2026
Facility Type Ambulatory Surgery Center
Lab Director BRYCE KIM

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