05D1072542 CLIA NUMBER - COSTA MESA MEDICAL CLINIC

Laboratory Demographics

CLIA Number: 05D1072542

Facility Name: COSTA MESA MEDICAL CLINIC

Facility Address:
745 W 19TH STREET SUITE F
COSTA MESA, CA
ZIP 92627
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Facility Phone Number: 949 574-0210

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1598902660

Taxonomy: 261QP2300X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	05D1072542
LAB Type	Physician Office
Facility Name	COSTA MESA MEDICAL CLINIC
Street	745 W 19TH STREET SUITE F
City	COSTA MESA
State	CA
ZIP	92627
Phone	949 574-0210
CertificateType	4
CertificateEffectiveDate	8/17/2023
CertificateExpirationDate	8/16/2025
FacilityType	Waiver

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