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05D1061621 CLIA NUMBER - LAKESIDE MEDICAL ORGANIZATION, A MEDICAL GRP, INC

Laboratory Demographics

CLIA Number: 05D1061621

Facility Name: LAKESIDE MEDICAL ORGANIZATION, A MEDICAL GRP, INC

Facility Address:
1500 S CENTRAL AVE STE 200
GLENDALE, CA
ZIP 91204
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Facility Phone Number: 818 254-1500

Facility Type: Physician Office

Certificate Type: Waiver
NPI Number: 1851409874

Taxonomy: 207RR0500X - Internal Medicine
An internist who treats diseases of joints, muscle, bones and tendons. This specialist diagnoses and treats arthritis, back pain, muscle strains, common athletic injuries and collagen diseases.

CLIA Record

Field Name Field Value
CLIA Number 05D1061621
LAB Type Physician Office
Facility Name LAKESIDE MEDICAL ORGANIZATION, A MEDICAL GRP, INC
Street 1500 S CENTRAL AVE STE 200
City GLENDALE
State CA
ZIP 91204
Phone 818 254-1500
CertificateType 4
CertificateEffectiveDate 11/21/2022
CertificateExpirationDate 11/20/2024
FacilityType Waiver

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