05D1070313 CLIA NUMBER - SHIRLEY'S ICF/DD-H NO 4

Laboratory Demographics

  • CLIA Code: 05D1070313
  • Facility Name: SHIRLEY'S ICF/DD-H NO 4
  • Facility Address: 3507 ADMIRAL DRIVE
    STOCKTON, CA
    ZIP 95209
  • Facility Phone: 209 952-3189
  • Facility Type: Intermediate Care Facility for Mentally Retarded
  • Facility Type: Waiver
  • Lab Director: RAGHUNATH K. REDDY
  • NPI Number: 1417009507
  • Taxonomy: 313M00000X - Nursing Facility/Intermediate Care Facility

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CLIA Record

Field Name Field Value
CLIA Number 05D1070313
LAB Type Intermediate Care Facility for Mentally Retarded
Facility Name SHIRLEY'S ICF/DD-H NO 4
Street 3507 ADMIRAL DRIVE
City STOCKTON
State CA
ZIP 95209
Phone 209 952-3189
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 6/26/2025
Certificate Expiration Date 6/25/2027
Facility Type Intermediate Care Facility for Mentally Retarded
Lab Director RAGHUNATH K. REDDY

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